3901.80 Accrediting independent review organizations.
3901.80 Accrediting independent review organizations.
As used in sections 3901.80 to 3901.83 of the Revised Code, “clinical peer” and “physician” have the same meanings as in section 1751.77 of the Revised Code.
(A) The superintendent of insurance shall accredit independent review organizations for the purposes of external reviews conducted under sections 1751.84, 1751.85, 3923.67, 3923.68, 3923.76, and 3923.77 of the Revised Code. The superintendent may, in accordance with Chapter 119. of the Revised Code and in consultation with the director of health, adopt rules governing the accreditation of independent review organizations. In developing the rules, the superintendent may take into consideration the standards established by national organizations that accredit organizations providing expert reviews and related services. The superintendent, after reviewing the accreditation process used by a national organization to accredit an independent review organization, may determine that accreditation by the national organization constitutes accreditation by the superintendent. The superintendent shall not accredit any independent review organization that is operated by a national, state, or local trade association of health benefit plans or health care providers.
(B) Each independent review organization shall use the services of clinical peers outside the staff of the independent review organization to conduct external reviews. None of the following shall choose, or control the choice of, the clinical peers:
(1) A health insuring corporation;
(2) An enrollee;
(3) An insurer;
(4) An insured;
(5) A public employee benefit plan;
(6) A plan member.
(C) The superintendent shall maintain a randomly organized roster of independent review organizations accredited under this section for purposes of assigning independent review organizations to conduct external reviews. The superintendent may, in accordance with Chapter 119. of the Revised Code, adopt rule governing the assignment of independent review organizations.
On receipt of a request by a health insuring corporation, insurer, or public employee benefit plan, the superintendent shall randomly assign two independent review organizations that are accredited under division (A) of this section. After receipt of the names of the two independent review organizations, the health insuring corporation, insurer, or public employee benefit plan shall select one of the assigned independent review organizations to conduct the external review.
No health insuring corporation, insurer, or public employee benefit plan shall engage in a pattern of excluding a particular independent review organization based on previous findings on behalf of enrollees, insureds, or plan members. If the superintendent makes such a finding, it is an unfair trade practice.
Effective Date: 05-01-2000