2023 Laws of Puerto Rico › TITLE TWENTY-SIX - Insurance (§§ 101 — 10377) › Subtitle 3 - Puerto Rico Health Insurance Code (§§ 9001 — 10377) › Chapter 126 - External Review (§§ 9501 — 9517) › § 9513 - Minimum requirements of capacity and competence for independent review organizations

(a) To be approved by the Commissioner 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 that include, at least:
(1) A quality assurance mechanism 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 proper selection of qualified and impartial clinical reviewers; the entity must have written policies and procedures so that reviewers may reveal any conflict of interest;
(C) ensures the confidentiality of medical records and clinical review criteria, and
(D) ensures that any person employed or contracted by the independent review organization adheres to the requirements of this chapter.
(2) A toll-free telephone service to receive information related to external reviews. The telephone service shall operate on a 24-hour-day, 7-days-a-week basis and be capable of accepting, recording or providing appropriate instruction to incoming telephone callers during other than normal business hours.
(3) Agree to maintain and provide to the Commissioner the information set out in § 9515 of this title.
(b) All clinical reviewers assigned by an independent review organization to conduct external reviews shall be physicians or other healthcare providers who meet the following minimum qualifications:
(1) Be an expert in the treatment of the covered person or enrollee's medical condition;
(2) be knowledgeable about the recommended or requested healthcare service or treatment. Such knowledge must have been acquired through recent or current actual clinical experience treating patients with the same or similar medical condition of the covered person or enrollee;
(3) hold a non-restricted license in a state of the United States or in Puerto Rico and, for physicians, a current certification by a medical specialty board recognized in the United States or Puerto Rico in the area or areas appropriate to the subject of the external review, and
(4) have no history of disciplinary actions or sanctions that raise a substantial question as to the clinical reviewer's physical, mental or professional competence or moral character.
(c) In addition to the requirements set forth in subsection (a) of this section, an independent review organization may not own or control, be a subsidiary of or in any way be controlled by, or exercise control with a health plan or a professional association of healthcare providers.
(d)
(1) In addition to the requirements set forth in subsections (a), (b), and (c) of this section, to be approved to conduct an external review of a specified case, neither the independent review organization nor any clinical reviewer assigned may have a material professional or familial interest or financial conflict of interest with any of the following:
(A) The health insurance organization or issuer involved;
(B) the covered person or enrollee who requested external review;
(C) any officer, director or management employee of the health insurance organization or issuer involved;
(D) the healthcare provider, the healthcare provider's medical group or independent practice association recommending the healthcare service or treatment subject of the external review;
(E) the facility at which the recommended healthcare 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 or enrollee.
(2) In determining whether an independent review organization or a clinical reviewer has a material professional or familial interest or financial conflict of interest, the Commissioner shall take into consideration situations where the independent review organization or a clinical reviewer may have an apparent professional, familial or financial relationship or connection with a person described in clause (1) of this subsection, but that the characteristics of that relationship or connection are such that they are not a material conflict of interests that impairs them from conducting the external review.
(e)
(1) An independent review organization that is accredited by an accrediting entity recognized by the Commissioner, whose independent review organization accreditation standards, in the judgment of the Commissioner, are equivalent to or exceed the minimum requirements of capacity and competence established under this section shall be presumed in compliance with this section to be eligible for approval under § 9512 of this title.
(2) The Commissioner shall initially and periodically review the independent review organization accreditation standards of accrediting entities to determine whether the entity's standards are, and continue to be, equivalent to or exceed the minimum requirements of capacity and competence established under this section. To comply with the review duty imposed herein, the Commissioner may accept a review conducted by the NAIC of accrediting organizations.
(3) Upon request, accrediting entities shall make their independent review organization accreditation standards available to the Commissioner in order for him/her to make the corresponding determinations pursuant to this chapter.
(f) An independent review organization shall be unbiased and shall establish and maintain written procedures to ensure that it is unbiased in addition to any other requirement under this chapter.
History —Aug. 29, 2011, No. 194, added as § 28.140 on Aug. 23, 2012, No. 203, § 7, eff. 90 days after Aug. 23, 2012.