Timeframes And Processes For Iro Review

A. Type of IRO review. The IRO shall conduct either a standard or expedited review of the adverse determination, as required by the medical exigencies of the case. (1) The IRO shall complete an expedited external review and provide notice of its decision to the grievant, the provider, the health care insurer, and the superintendent as required by the medical exigencies of the case as soon as possible, but in no case later than 72 hours after appointment by the superintendent. If notice of the IRO’s decision is initially provided by telephone, written notice of the decision shall be provided within 48 hours after the telephone notification. (2) The IRO shall complete a standard external review and provide written notice of its decision to the grievant, the provider, the health care insurer and the superintendent within 20 days after appointment by the superintendent. B. Expedited IRO review, timeframe and process. (1) In cases involving an urgent care claim, the superintendent shall immediately upon receipt of a request for an expedited IRO review send the grievant an acknowledgment that the request has been received and send a copy of the request to the health insurer. (2) Within 24 hours or the time limit set by the superintendent following receipt of a request for an expedited IRO review from the superintendent, the health care insurer shall complete a preliminary review of the matter to determine whether the request is eligible for IRO review, and shall report immediately to OSI upon completion of the preliminary review, as follows: (a) the grievant is or was a covered person in the health benefit plan at the time the health care service was requested; (b) the health care service that is the subject of the request for IRO review 13.10.17 NMAC 16 reasonably appears to be a covered benefit under the grievant’s health benefit plan, but for a determination by the health care insurer that the requested service is not covered because it is experimental, investigational, or not medically necessary; and (c) the grievant has or is not required to exhaust the health carrier’s internal grievance process. (3) If the request is not complete, the health care insurer shall inform the grievant, provider and the superintendent telephonically and electronically and include in the notice what information or materials are needed to make the request complete. (4) If the request is not eligible for IRO review, the health care insurer shall inform the grievant, provider and the superintendent telephonically and electronically and include in the notice the reasons for ineligibility and a statement that the health care insurer’s determination of ineligibility may be appealed to the superintendent. (5) MHCB will confirm or obtain from the grievant all information and forms required to process an expedited IRO review, including the signed release form. (6) Upon receipt of the health care insurer’s notice that a request is complete and eligible for IRO review and the confirmation from MHCB, the superintendent will immediately randomly assign an IRO from the superintendent’s list of approved IROs to conduct an expedited review, and shall: (a) notify the health care insurer of the name of the assigned IRO; and (b) notify the grievant and the provider of the name of the assigned IRO, that the health care insurer will provide to the IRO all of the documents and information considered in making the adverse determination, and that the grievant and provider may provide additional information. (7) The superintendent may determine that a request is eligible for an expedited IRO review notwithstanding a health care insurer’s initial determination that the request is incomplete or ineligible. In making an eligibility determination, the superintendent’s decision shall be made in accordance with the terms of the grievant’s health benefit plan. (8) MHCB will immediately provide to the assigned IRO and to the health care insurer all information and forms obtained from the grievant, including a signed release form. (9) Within 24 hours from the date of the notice from the superintendent that the IRO has been appointed, the grievant or the provider may also submit additional documentation or information to the IRO; the IRO shall immediately forward any documentation or information received from the grievant to the health care insurer. (10) Upon receipt of the superintendent’s notice that an IRO has been appointed, the health care insurer shall within 24 hours provide to the assigned IRO, any information considered in making the adverse determination, including, but not limited to: (a) the summary of benefits; (b) the complete health benefits plan, which may be in the form of a member handbook/evidence of coverage; (c) all pertinent medical records, internal review decisions and rationales, consulting physician reports, and documents and information submitted by the grievant and health care insurer; (d) uniform standards relevant to the grievant’s medical condition that were used by the internal panel in reviewing the adverse determination; and (e) any other documents, records, and information relevant to the adverse determination and the internal review decision(s). (11) Failure by the health care insurer to provide the documents and information required by this rule within the time specified shall not delay the conduct of the IRO external review. If the health care insurer fails to provide the documents and information within the time specified, the assigned IRO may terminate the review and make a decision to reverse the adverse determination. C. Standard IRO review, timeframe and process. (1) Within one day after the date of receipt of a request for an IRO review, the superintendent shall send the grievant an acknowledgment that the request has been received and send a copy of the request to the health insurer. (2) Within five days following the receipt of the IRO review request from the superintendent, the health insurer shall complete a preliminary review of the request to determine whether the request is eligible for IRO review, as follows: (a) the grievant is or was a covered person in the health benefit plan at the time the health care service was requested or, in the case of a retrospective review, was a covered person in the health benefit 13.10.17 NMAC 17 plan at the time the health care service was provided; (b) the health care service that is the subject of the request for IRO review reasonably appears to be a covered service under the grievant’s health benefit plan, but for a determination by the health care insurer that the requested health care service is not covered because it is experimental, investigational, or not medically necessary; (c) for experimental or investigational adverse determinations, the grievant's treating physician certified, in writing, that one of the following applies: (i) standard health care services or treatments have not been effective in improving the condition of the grievant; (ii) standard health care services or treatments are not medically appropriate for the grievant; (iii) there is no available standard health care service or treatment covered by the health benefits plan that is more beneficial than the recommended or requested health care service or treatment; (iv) the health care service or treatment requested is likely to be more beneficial to the grievant, in the physician’s opinion, than any available standard health care services or treatments; or (v) the grievant’s treating physician, who is licensed, board certified or board eligible to practice in the area of medicine appropriate to treat the grievant's condition, has certified in writing that scientifically valid studies using accepted protocols demonstrate that the health care service or treatment requested is likely to be more beneficial to the grievant than any available standard health care services or treatments. (d) the grievant has exhausted or is not required to exhaust the health care insurer’s internal grievance process; and (e) the grievant has provided all the information and forms required to process an IRO review, including the signed release form. (3) Upon completion of the preliminary review, the health care insurer shall notify the superintendent and grievant in writing within one day whether: (a) the request is complete; and (b) the request is eligible for IRO review. (4) If the request: (a) is not complete, the health care insurer shall inform the grievant and the superintendent in writing and include in the notice what information or material are needed to make the request complete; or (b) is not eligible for an IRO review, the health care insurer shall inform the grievant and the superintendent in writing and include in the notice the reasons for its ineligibility. (5) The notice of initial determination shall include a statement informing the grievant that a health care insurer’s initial determination of ineligibility for IRO review may be appealed to the superintendent. (6) The superintendent may determine that a request is eligible for an IRO review notwithstanding a health care insurer’s initial determination that the request is ineligible and require that it be referred to an IRO. In making an eligibility determination, the superintendent’s decision shall be made in accordance with the terms of the grievant’s health benefit plan. (6) Even after the superintendent assigns a grievance to an IRO for review, the MHCB may attempt to resolve the grievance between the health care insurer and the grievant. If the matter is successfully resolved, OSI will immediately notify the IRO to terminate work. D. Assignment of IRO by superintendent. (1) Within one day of receipt of a notice that the health care insurer has determined a request is eligible for an IRO review, the superintendent shall: (a) randomly assign an IRO from the superintendent’s list of approved IROs to conduct the review; (b) notify the health care insurer of the name of the assigned IRO; (c) notify the grievant in writing that the request is eligible for an IRO external review, the name of the assigned IRO, and that the health care insurer will provide all of the documents and information considered by the health care insurer in making the adverse determination; and (d) notify the grievant that the grievant may submit in writing to the assigned IRO within five days following the date of receipt of the notice, any additional information that the IRO shall consider 13.10.17 NMAC 18 when conducting the review. The IRO is not required to, but may, accept and consider additional information submitted after five days. (2) If the adverse determination is based on a determination that the requested service is experimental, investigational, or not medically necessary, then the superintendent shall direct the IRO to utilize a panel of appropriate clinical peer(s) of the same or similar specialty as would typically manage the case being reviewed. (3) Within one day after the receipt of the notice of assignment by the superintendent to conduct the external review, the assigned IRO shall select up to three clinical reviewers. (4) Within five days following the notice of the assigned IRO, the health care insurer shall provide to the assigned IRO all documents and any information considered in making the adverse determination, including, but not limited to: (a) the summary of benefits; (b) the complete health benefits plan, which may be in the form of a member handbook/evidence of coverage; (c) all pertinent medical records, internal review decisions and rationales, consulting physician reports, and documents and information submitted by the grievant and health care insurer; (d) uniform standards relevant to the grievant’s medical condition that were used by the internal panel in reviewing the adverse determination; and (e) any other documents, records, and information relevant to the adverse determination and the internal review decision(s). (5) Failure by the health care insurer to provide the documents and information required by this rule within the time specified shall not delay the conduct of the external review. If the health care insurer fails to provide the documents and information within the time specified, the assigned IRO may terminate the review and make a decision to reverse the adverse determination. Within one day after making such a decision, the IRO shall notify the grievant, the provider, the health care insurer, and the superintendent. (6) If the grievant provides additional supporting documents or information to the IRO: (a) The IRO shall send any information received from grievant to the health care insurer within one day. (b) Upon receipt of such information, the health care insurer may reconsider its adverse determination. (7) If, upon such review, the health care insurer reverses its prior decision, it shall within one day provide written notification of its decision to the grievant, the provider, the assigned IRO and the superintendent. (a) If the health care insurer reverses its prior decision, the assigned IRO shall terminate its review upon receipt of the notice from the health care insurer. (b) Upon reversing its prior decision, the health care insurer shall approve coverage for the health care service subject to any applicable cost sharing including co-payments, co-insurance and deductible amounts for which the grievant is responsible. (c) The health care insurer shall compensate the IRO according to the published fee schedule whenever the IRO review is terminated prior to completion. [13.10.17.22 NMAC - Rp, 13.10.17.27 NMAC, 1/1/2017; A, 11/19/2024] 13.10.17.23 THE FINAL DECISION OF THE IRO AND GRIEVANT’S RIGHT TO HEARING AFTER FINAL IRO DECISION: A. Independent decision. In reaching its decision, the IRO is not bound by the prior decision of the health care insurer. In addition to the documents and information provided to the IRO by the health care insurer and the grievant and to the extent such documents are available, each reviewer shall consider the following in reaching its decision: (1) the grievant’s medical records; (2) the attending health care professional’s recommendation; (3) consulting reports from appropriate health care professionals and other documents submitted by the health care insurer, the grievant, or the treating health care professional; (4) the terms of coverage under the applicable health benefit plan to ensure that the IRO’s decision is not contrary to the terms of coverage; (5) the most appropriate practice guidelines, which shall include applicable evidence-based standards and may include any other practice guidelines developed by the federal government, national or 13.10.17 NMAC 19 professional medical societies, boards and associations; (6) any applicable clinical review criteria and policies developed and used by the health care insurer; and (7) the opinion of the IRO’s clinical reviewer(s) after considering the information received. B. Opinion of clinical reviewer. Each clinical reviewer selected shall provide an opinion to the assigned IRO as to whether the recommended or requested health care service should be covered as follows: (1) for a standard external review, each clinical reviewer shall provide a written opinion to the IRO within the time constraints set by this rule; (2) for an expedited external review, each clinical reviewer shall provide an opinion orally or in writing to the IRO as expeditiously as the covered person’s medical condition or circumstances requires. If the opinion is provided orally, each clinical reviewer shall provide a written opinion to the IRO within 48 hours after providing the oral opinion; and (3) each clinical reviewer’s written opinion shall include the following information: (a) a description of the covered person’s medical condition; (b) whether there is sufficient evidence to demonstrate that the requested health care service is more likely than not to be more beneficial to the covered person than any available standard health care services and that the adverse risks of the requested health care service would not be substantially increased over those of available standard health care services; (c) a description and analysis of any medical or scientific evidence considered in reaching the opinion; (d) a description and analysis of any evidence-based standards; (e) the reviewer’s rationale for the opinion; and (f) whether the recommended or requested health care service has been approved by the federal food and drug administration, if applicable, for the condition. C. Decision of the IRO. Based upon the opinion of the clinical reviewer(s), the IRO shall issue notice of its decision in the manner set forth in this rule. (1) If a majority of clinical reviewers recommend that the requested health care service should be covered, the IRO shall reverse the health care insurer’s adverse determination. (2) If a majority of clinical reviewers recommend that the requested health care service should not be covered, the IRO shall uphold the health care insurer’s adverse determination. D. Content of IRO’s notice. Notice of the IRO’s decision shall be sent to the grievant, the provider, the health care insurer, and the superintendent and shall include: (1) a general description of the reason for the request for external review; (2) the date the IRO was appointed; (3) the date the review by the IRO was completed; (4) the principal reason(s) for its decision, including any applicable evidence-based standards that were the basis for the decision; (5) reference to the evidence or documentation that was considered in reaching the decisions; (6) the rationale for the decision; and (7) the written opinion of each clinical reviewer as to whether the recommended or requested health care service or treatment should be covered and the rationale for each reviewer’s recommendation. E. Binding decision. The decision of the IRO is binding upon the health care insurer except to the extent that the health care insurer may pursue other remedies under applicable state and federal law. The decision is also binding upon the grievant except to the extent that the grievant may pursue other remedies under applicable state and federal law, including the grievant’s right to appeal to the superintendent for a hearing. (1) This requirement that the decision is binding shall not preclude the health care insurer from making payment on the claim or otherwise providing benefits at any time, including after an IRO’s decision or following an external review by the superintendent that denies the claim or otherwise fails to require such payment or benefits. (2) Upon receipt of a decision by an IRO reversing an adverse determination, the health care insurer shall approve coverage for the health care service for which the IRO review was conducted, subject to any applicable co-payment, co-insurance and deductible amounts for which the grievant is responsible without delay, regardless of whether the health care insurer intends to seek judicial review of the external review decision and unless or until there is a final judicial decision otherwise.