Minimum Qualifications for Independent Review Organizations

Minimum Qualifications for Independent Review Organizations A. To be approved under Rule 15.11 of this Regulation to conduct external reviews, an independent review organization shall have and maintain written policies and procedures that govern all aspects of both the standard external review process and the expedited external review process set forth in this Regulation that include, at a minimum: 1. A quality assurance mechanism in place that: a. Ensures that external reviews are conducted within the specified time frames and required notices are provided in a timely manner; b. Ensures the selection of qualified and impartial clinical reviewers to conduct external reviews on behalf of the independent review organization and suitable matching of reviewers to specific cases and that the independent review organization employs or contracts with an adequate number of clinical reviewers to meet this objective; c. Ensures the confidentiality of medical and treatment records and clinical review criteria; and d. Ensures that any person employed by or under contract with the independent review organization adheres to the requirements of this Regulation; 2. A toll-free telephone service to receive information on a 24-hour-day, 7- day-a-week basis related to external reviews that is capable of accepting, recording or providing appropriate instruction to incoming telephone callers during other than normal business hours; and 3. Agree to maintain and provide to the Commissioner the information set out in Rule 15.14 of this Regulation. B. All clinical reviewers assigned by an independent review organization to conduct external reviews shall be physicians or other appropriate health care providers who meet the following minimum qualifications: C. 1. Be an expert in the treatment of the covered person’s medical condition that is the subject of the external review; 2. Be knowledgeable about the recommended health care service or treatment through recent or current actual clinical experience treating patients with the same or similar medical condition of the covered person; 3. Hold a non-restricted license in a State of the United States and, for physicians, a current certification by a recognized American medical specialty board in the area or areas appropriate to the subject of the external review; and 4. Have no history of disciplinary actions or sanctions, including loss of staff privileges or participation restrictions, that have been taken or are pending by any hospital, governmental agency or unit, or regulatory body that raise a substantial question as to the clinical reviewer’s physical, mental or professional competence or moral character. D. In addition to the requirements set forth in subsection A, an independent review organization may not own or control, be a subsidiary of or in any way be owned or 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. E. 1. In addition to the requirements set forth in subsections A, B and C, to be approved pursuant to Rule 15.11 of this Regulation to conduct an external review of a specified case, neither the independent review organization selected to conduct the external review nor any clinical reviewer assigned by the independent organization to conduct the external review may have a material professional, familial or financial conflict of interest with any of the following: a. The health carrier that is the subject of the external review; b. The covered person whose treatment is the subject of the external review or the covered person’s authorized representative; c. Any officer, director or management employee of the health carrier that is the subject of the external review; d. The health care provider, the health care provider’s medical group or independent practice association recommending the health care service or treatment that is the subject of the external review; e. The facility at which the recommended health care service or treatment would be provided; or f. The developer or manufacturer of the principal drug, device, procedure or other therapy being recommended for the covered person whose treatment is the subject of the external review. 2. In determining whether an independent review organization or a clinical reviewer of the independent review organization has a material professional, familial or financial conflict of interest for purposes of paragraph (1), the Commissioner shall take into consideration situations where the independent review organization to be assigned to conduct an external review of a specified case or a clinical reviewer to be assigned by the independent review organization to conduct an external review of a specified case may have an apparent professional, familial or financial relationship or connection with a person described in paragraph (1), but that the characteristics of that relationship or connection are such that they are not a material professional, familial or financial conflict of interest that results in the disapproval of the independent review organization or the clinical reviewer from conducting the external review. F. 1. An independent review organization that is accredited by a nationally recognized private accrediting entity that has independent review accreditation standards that the Commissioner has determined are equivalent to or exceed the minimum qualifications of this section shall be presumed in compliance with this section to be eligible for approval under