§ 58-50-87. Minimum qualifications for independent review organizations.
§ 58‑50‑87. Minimum qualifications for independent review organizations.
(a) As a condition ofapproval under G.S. 58‑50‑85 to conduct external reviews, anindependent review organization shall have and maintain written policies andprocedures that govern all aspects of both the standard external review processand the expedited external review process set forth in G.S. 58‑50‑80and G.S. 58‑50‑82 that include, at a minimum:
(1) A quality assurancemechanism in place that ensures:
a. That externalreviews are conducted within the specified time frames and required notices areprovided in a timely manner.
b. The selection ofqualified and impartial clinical peer reviewers to conduct external reviews onbehalf of the independent review organization and suitable matching ofreviewers to specific cases.
c. The confidentialityof medical and treatment records and clinical review criteria.
d. That any personemployed by or under contract with the independent review organization adheresto the requirements of this Part.
e. The independence andimpartiality of the independent review organization and the external reviewprocess and limits the ability of any person to improperly influence theexternal review decision.
(2) A toll‑freetelephone service to receive information on a 24‑hour‑day, seven‑day‑a‑weekbasis related to external reviews that is capable of accepting or recordinginquiries or providing appropriate instruction to incoming telephone callersduring other than normal business hours.
(3) An agreement to maintainand provide to the Commissioner the information set out in G.S. 58‑50‑90.
(4) A program forcredentialing clinical peer reviewers.
(5) An agreement tocontractual terms or written requirements established by the Commissionerregarding the procedures for handling a review.
(6) That the independentreview organization consult with a medical doctor licensed to practice in NorthCarolina to advise the independent review organization on issues related to thestandard of practice, technology, and training of North Carolina physicianswith respect to the organization's North Carolina business.
(b) All clinical peerreviewers assigned by an independent review organization to conduct externalreviews shall be medical doctors or other appropriate health care providers whomeet the following minimum qualifications:
(1) Be an expert in thetreatment of the covered person's injury, illness, or medical condition that isthe subject of the external review.
(2) Be knowledgeableabout the recommended health care service or treatment through recent orcurrent actual clinical experience treating patients with the same or similarinjury, illness, or medical condition of the covered person.
(3) If the coveredperson's treating provider is a medical doctor, hold a nonrestricted licenseand, if a specialist medical doctor, a current certification by a recognizedAmerican medical specialty board in the area or areas appropriate to thesubject of the external review.
(4) If the coveredperson's treating provider is not a medical doctor, hold a nonrestrictedlicense, registration, or certification in the same allied health occupation asthe covered person's treating provider.
(5) Have no history ofdisciplinary actions or sanctions, including loss of staff privileges orparticipation restrictions, that have been taken or are pending by anyhospital, governmental agency or unit, or regulatory body that raise asubstantial question as to the clinical peer reviewer's physical, mental, orprofessional competence or moral character.
(c) In addition to therequirements set forth in subsection (a) of this section, an independent revieworganization may not own or control, be a subsidiary of, or in any way be ownedor controlled by, or exercise control with a health benefit plan, a national,State, or local trade association of health benefit plans, or a national,State, or local trade association of health care providers.
(d) In addition to therequirements set forth in subsections (a), (b), and (c) of this section, to beapproved under G.S. 58‑50‑85 to conduct an external review of aspecified case, neither the independent review organization selected to conductthe external review nor any clinical peer reviewer assigned by the independentorganization to conduct the external review may have a material professional,familial, or financial conflict of interest with any of the following:
(1) The insurer that isthe subject of the external review.
(2) The covered personwhose treatment is the subject of the external review or the covered person'sauthorized representative.
(3) Any officer,director, or management employee of the insurer that is the subject of theexternal review.
(4) The health careprovider, the health care provider's medical group, or independent practiceassociation recommending the health care service or treatment that is thesubject of the external review.
(5) The facility atwhich the recommended health care service or treatment would be provided.
(6) The developer ormanufacturer of the principal drug, device, procedure, or other therapy beingrecommended for the covered person whose treatment is the subject of theexternal review.
(e) In determiningwhether an independent review organization or a clinical peer reviewer of theindependent review organization has a material professional, familial, orfinancial conflict of interest for purposes of subsection (d) of this section,the Commissioner shall take into consideration situations where the independentreview organization to be assigned to conduct an external review of a specifiedcase or a clinical peer reviewer to be assigned by the independent revieworganization to conduct an external review of a specified case may have anapparent professional, familial, or financial relationship or connection with aperson described in subsection (d) of this section, but that thecharacteristics of that relationship or connection are such that they are not amaterial professional, familial, or financial conflict of interest that resultsin the disapproval of the independent review organization or the clinical peerreviewer from conducting the external review. (2001‑446, s. 4.5.)