Conflict of Interest

(1) External review agencies shall ensure that the External Review Agency and the external reviewers assigned to any external review: (a) Shall have no Material Professional, Material Familial, or Financial Affiliation with any party that is the subject of the review; and (b) Shall have no Material Professional, Material Familial or Financial Affiliation with any party that participated in the denial or restriction that is the subject of review. (2) The Office of Patient Protection shall not contract with any External Review Agency which owns or controls, or is owned or controlled by a Carrier or utilization review organization or an RBPO or ACO, the sponsor of a group health plan, a trade association plans or issuers, or a trade association of Health Care Providers. (3) Decisions by the External Review Agency regarding the hiring, compensation, termination, promotion, or other similar matters with respect to the external reviewer must not be based upon the likelihood that that the external reviewer will support the denial or restriction of care.