Conflict of Interest

(1) External review agencies shall ensure that the external review agency and the clinical reviewers assigned to any external review: (a) shall have no material professional, familial or financial affiliation with any party that is the subject of the review; (b) shall have no material professional, family or financial affiliation with any party that participated in the delivery of health care to the insured who is the subject of the review: 1. shall not have participated as a clinical reviewer in connection with any medical necessity determination with respect to the insured who is the subject of the review; and 2. shall have no material professional, familial or financial conflict of interest with any officer, director, or management employee of the carrier or utilization review organization; the plan administrator, plan fiduciaries, or plan employees; the health care provider, the health care provider's group, or practice association recommending the treatment that is subject to the external review; the facility at which the recommended treatment would be provided; or the developer or manufacturer of the principal drug, device, procedure, or other therapy being recommended. (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, the sponsor of a group health plan, a trade association of 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 reviewer must not be based upon the likelihood that the reviewer will support the denial of benefits.