Iro Review Of An Adverse Determination

A. Right to external IRO review. Every grievant who is dissatisfied with an adverse determination following internal review of a grievance that involves medical judgment, including a determination based on medical necessity, appropriateness, health care setting, level of care, effectiveness or that the requested health care service is experimental, investigational or unproven for a particular medical condition may request an external review by an impartial IRO appointed by the superintendent at no cost to the grievant. B. Exhaustion of internal review process. The superintendent may require the grievant to exhaust any required grievance procedures adopted by the health care insurer or the entity that purchases health care benefits pursuant to the New Mexico Health Care Purchasing Act, as appropriate, before accepting a grievance for IRO review. 13.10.17 NMAC 13 C. Deemed exhaustion. If exhaustion of internal reviews is required prior to IRO review, exhaustion is unnecessary and the internal reviews process will be deemed exhausted if: (1) the health care insurer waives the exhaustion requirement; (2) the health care insurer is considered to have exhausted the internal review process by failing to comply with the requirements of the internal review process; or (3) the grievant simultaneously requests an expedited internal review and an expedited IRO review. D. Exception to exhaustion requirement. (1) Notwithstanding Subsection C of 13.10.17.19 NMAC, the internal review process will not be deemed exhausted based on violations by the health care insurer that are de minimus and do not cause, and are not likely to cause, prejudice or harm to the grievant, so long as the health care insurer demonstrates that the violation was for good cause or due to matters beyond the control of the health care insurer, and that the violation occurred in the context of an on-going, good faith exchange of information between the health care insurer and the grievant. This exception is not available if the violation is part of a pattern or practice of violations by the health care insurer, as determined by the superintendent. (2) The grievant may request a written explanation of the violation from the health care insurer, and the health care insurer must provide such explanation within 10 days, including a specific description of its bases, if any, for asserting that the violation should not cause the internal review process to be deemed exhausted. If an external reviewer or a court rejects the grievant’s request for immediate review on the basis that the health care insurer met the standards for the exception under Paragraph (1) of Subsection D of 13.10.17.19 NMAC, the grievant has the right to re-submit and pursue a request for review of the claim. In such a case, within a reasonable time after the external reviewer or court rejects the claim for immediate review (not to exceed 10 days), the health care insurer shall provide the grievant with notice of the opportunity to re-submit and pursue the internal review of the claim. Time periods for re-filing the claim shall begin to run upon grievant’s receipt of such notice. E. IRO fees. The health care insurer against which a request for external review has been filed shall be responsible for paying the fees of the IRO. The health care insurer shall remit payment to the IRO within 30 days after its receipt of the invoice. (1) The superintendent shall determine the reasonable compensation for IROs and shall publish a schedule of IRO compensation by bulletin. (2) Upon completion of the review, the IRO shall submit its invoice directly to the health care insurer. F. In reaching a decision, the assigned IRO is not bound by any decisions or conclusions reached during the health care insurer’s utilization review process or the health care insurer’s internal grievance process. G. Nothing in this rule shall preclude the health care insurer and grievant from resolving the matter prior to completion of the IRO review. H. A grievant may not file a subsequent request for external review by an IRO involving the same adverse determination for which the grievant has already received an external IRO review under this rule. [13.10.17.19 NMAC - Rp, 13.10.17.24 NMAC, 1/1/2017; A, 11/19/2024] 13.10.17.20 QUALIFICATIONS OF IROs AND APPROVAL BY SUPERINTENDENT: A. Superintendent’s list. The superintendent shall compile and maintain a list of approved IROs. B. IRO requirements. To be considered for placement on the list of approved IROs, an IRO shall: (1) be accredited by a nationally recognized private accrediting entity; (2) meet the requirements of this rule; and (3) have quality assurance mechanisms that ensure that clinical reviewers assigned to conduct the external review are qualified and impartial physicians or other appropriate health care providers who; (a) have expertise in the treatment of grievant’s medical condition; (b) hold a non-restricted license in a state of the United States and, for physicians, a current certification by a recognized medical specialty board in the area(s) appropriate to the subject of the IRO review; and (c) 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 substantial questions about the clinical reviewer’s physical, mental or professional competence or moral character. (4) have written policies and procedures that ensure: 13.10.17 NMAC 14 (a) all reviews are conducted within the timeframe specified by this rule and required notices are provided in a timely manner; (b) the selection of qualified and impartial physicians or other appropriate health care professionals to act as clinical reviewers based on the requirements of specific cases and that the IRO employs or contracts with an adequate number of clinical reviewers to meet this objective; (c) the confidentiality of medical and treatment records and clinical review criteria; and (d) that any person employed by or under contract with the IRO adheres to the requirements of this rule. (5) maintain a toll-free telephone service to receive information 24 hours a day, seven days per 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. C. Applicants for the IRO list. An applicant requesting placement on the list of approved IROs shall submit for the superintendent’s review: (1) an IRO application form available on the OSI website; (2) all documentation and information requested on the application, including proof of being accredited by a nationally recognized private accrediting entity; (3) any applicable application fee pursuant to § 59A-6-1 (BB); and (4) completion of a memorandum of understanding, to be supplied by OSI. D. Termination of IRO. The superintendent shall, in the superintendent’s sole discretion, terminate the approval of an IRO if the superintendent determines that the IRO has lost its accreditation or no longer satisfies the minimum requirements for approval. E. Conflict of interest by an IRO. (1) An IRO may not own or control, be a subsidiary of or in any way be owned or controlled by, or exercise control with a health care insurer, a national, state or local trade association of health care insurers, or a national, state or local trade association of health care providers. (2) Neither an IRO appointed to conduct the independent review nor any clinical reviewer assigned by an IRO to conduct a review may have a material, professional, familial or financial conflict of interest with: (a) the health care insurer that is the subject of the IRO review; (b) an officer, director, manager or management employee of the health care insurer that is the subject of the IRO review; (c) the health benefits plan; (d) the plan administrator, plan fiduciaries or plan employees; (e) the grievant or the grievant’s representative; (f) the grievant’s health care provider(s) or the provider’s medical group, who is recommending the service or treatment that is the subject of the review; (g) the health care provider’s medical group or independent practice association; (h) a health care facility where the service would be provided; or (i) the developer, manufacturer, distributor, or supplier of the principal drug, device, procedure or other service that is the subject of the appeal. F. Written procedures. An IRO shall establish and maintain written procedures to ensure that it is unbiased in addition to any other procedures required under this rule. G. Availability of records. An IRO shall keep and maintain written or electronic records and make available upon request by OSI, any record received or reviewed during an IRO review for a period of six years following the review. H. IRO’s report to OSI. An IRO shall keep and maintain written or electronic records of all IRO reviews it has conducted under this rule and make available to OSI every calendar year on January 15, a report that is organized by health care insurer and which includes: (1) the total number of reviews conducted; (2) the number of reviews resolved; and of those resolved, the number resolved upholding the adverse determination or final adverse determination of the health care insurer; (3) the total number resolved reversing the adverse determination or final adverse determination of the health care insurer; (4) the average length of time for the review; 13.10.17 NMAC 15 (5) a summary of the types of coverages or cases for which the review was sought, as provided in the format required by the superintendent; (6) the number of reviews that were terminated as a result of a reconsideration by the health care insurer of its adverse determination after the receipt of additional information from the grievant; and (7) any other information the superintendent may request or require. I. Contracts with health care insurers. Nothing in this rule precludes or shall be interpreted to preclude a health care insurer from contracting with an approved IRO to conduct peer or federal external reviews.