Illinois Administrative Code › Title 50 - INSURANCE › Part 4530 - HEALTH CARRIER EXTERNAL REVIEW › Appendix C - Independent Review Organizations - Application for Registration

Current through Register Vol. 48, No. 28, July 12, 2024
INDEPENDENT REVIEW ORGANIZATION
Registration Form
[Today's Date]
1. Name of Independent Review Organization
				____________________________
DBA
				___________________________________________________________
Type of Applicant (check one):
Corporation
Partnership
Limited Liability
Other (Describe)
				________________________________________________
FEIN: ______________________
Contact Person:
				___________________________________________________
Business Telephone Number: (
				)_______________________________________
Fax Number: (
				)____________________________________________________
Email Address:
				____________________________________________________
2. Business Address:
Street (Do Not Use P.O. Box):
				_________________________________________
City:
				_____________________________________________________________
State: _________________________________ Zip:
				_______________________
Telephone Number: (
				)________________________________________________
Website:
				__________________________________________________________
3. Mailing Address (If Different from Business Address):
Street (Do Not Use P.O. Box):
				__________________________________________
City:
				______________________________________________________________
State: __________________________________ Zip:
				_______________________
4. Contact Information To Be Used on the Department's Website
				of Approved Independent Review Organizations:
Contact Person:
				_____________________________________________________
Business Telephone Number: (
				)_________________________________________
Fax Number: (
				)______________________________________________________
Street (Do Not Use P.O. Box):
				___________________________________________
City:
				_______________________________________________________________
State: __________________________________ Zip:
				_______________________
5. Agent for Service of Process in Illinois Department of
				Insurance:
Street (Do Not Use P.O. Box):
				___________________________________________
Name:
				_____________________________________________________________
City:
				_______________________________________________________________
State: __________________________________ Zip:
				________________________
6. For Each Independent Review Program supply the following
				information:
a. The name, address, telephone number and hours of
				operation for the independent review program.
b. The organization and governing structure of the
				independent review program.
c. The number of reviews in Illinois for which an
				independent review is conducted by each independent review program for the
				current year.
d. Number of reviews in Illinois for which an
				independent review was conducted for the previous calendar year for each
				independent review program.
e. A copy of your most recent certificate from
				American Accreditation Healthcare Commission (URAC) Standards for Independent
				Review Organizations, if applicable.
f. Written policies and procedures for protection of
				confidential information according to applicable State and federal laws for
				each independent review program.
g. Biographical information for organization
				officers and directors. The biographical affidavits shall include, but not be
				limited to, the following information: identifying information; affiant's
				identifying and contact information; affiant's educational, residential and
				employment history; affiant's professional, business and technical licenses and
				memberships; a complete history of affiant's fidelity bonding; criminal charges
				and convictions; civil, regulatory, administrative and disciplinary actions in
				an individual or corporate capacity; a complete history of affiant's
				bankruptcy, insolvency, liens and foreclosures in an individual or corporate
				capacity; affiant's consent to release background reports to the Department and
				consent for third parties to cooperate in the gathering of background
				information; and affiant's and his or her immediate family's equity holdings in
				any entity subject to insurance regulation. The Department will accept the
				biographical affidavit, and any supplement to that affidavit, that is obtained
				from the website of the NAIC or the Department. Biographical affidavits shall
				be stamped "confidential" by the independent review organization.
h. A list of all contracted reviewers, the
				physician's license number of each reviewer and his or her contact information
				and area of clinical expertise.
i. All information required in 7 below.
7. Minimum Qualifications for Independent Review
				Organizations:
a. To be approved 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 the Act that include, at
				a minimum:
i. A quality assurance mechanism that ensures
				that:
A. External reviews are conducted within the
				specified timeframes and required notices are provided in a timely
				manner;
B. Selection of qualified and impartial clinical
				reviewers to conduct external reviews on behalf of the IRO 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. For adverse determinations involving experimental
				or investigational treatments, in assigning clinical reviewers, the independent
				review organization selects physicians or other health care professionals who,
				through clinical experience in the past 3 years, are experts in the treatment
				of the covered person's condition and knowledgeable about the recommended or
				requested health care service or treatment;
D. The health carrier, the covered person, and the
				covered person's authorized representative shall not choose or control the
				choice of the physicians or other health care professionals to be selected to
				conduct the external review;
E. Confidentiality of medical and treatment records
				and clinical review criteria;
F. Any person employed by or under contract with the
				independent review organization adheres to the requirements of the Act;
ii. A toll-free telephone service and email address
				operating on a 24 hours/day, 7 days/week basis that accepts, receives, and
				records information related to external reviews and provides appropriate
				instructions;
iii. Name, phone number and direct email address of
				contact persons who will be responsible for handling assignments of external
				reviews; and
iv. An agreement to maintain and provide to the
				Director the information set out in Section 65 of the Act.
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:
i. Be an expert in the treatment of the covered
				person's medical condition that is the subject of the external review;
ii. 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 as the covered
				person;
iii. 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
iv. 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.
c. 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.
d. Conflicts of interest are prohibited. In addition
				to the requirements set forth in 7a, 7b and 7c of this Section, to be approved
				pursuant to the Act 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 IRO to conduct the external review may
				have a material professional, familial or financial conflict of interest with
				any of the following:
i. The health carrier that is the subject of the
				external review;
ii. The covered person whose treatment is the
				subject of the external review or the covered person's authorized
				representative;
iii. Any officer, director or management employee of
				the health carrier that is the subject of the external review;
iv. 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;
v. The facility at which the recommended health care
				service or treatment would be provided; or
vi. 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.
e. An independent review organization shall be
				unbiased. An IRO shall establish and maintain written procedures to ensure that
				it is unbiased in addition to any other procedures required under this
				Section.
f. Nothing in this Section precludes or shall be
				interpreted to preclude a health carrier from contracting with approved
				independent review organizations to conduct external reviews assigned to it
				from the health carrier.
g. An independent review organization that meets or
				exceeds the accreditation standards for Independent Review Organizations set
				forth by the American Accreditation Healthcare Commission (URAC) and otherwise
				meets the qualifications of this Section shall be presumed to be in compliance
				with this Section and shall be eligible for approval.
8. Check Enclosed (Please make checks payable to Director of
				Insurance)
a. Accredited entity fee of $1000 biennially.
b. Unaccredited entity fee of $1500 biennially in
				the event that the Director determines that there are no acceptable nationally
				recognized private accrediting entities providing independent review
				organization accreditation.
9. Affirmation (to be signed by an officer or director of the
				independent review organization only):
I,
				______________________________________________________ do hereby certify
				that
(Typed name, title)
____________________________________________________________________
(Independent Review Organization)
complies with the Independent Review Organization
				Standards of the American Accreditation Healthcare Commission (URAC) and has
				submitted evidence of accreditation by URAC for Independent Review, and that
				the persons responsible for the conduct of
				___________________________________
(Independent Review Organization)
are competent, trustworthy, and possess good
				reputations, and have appropriate experience, training or education and do
				hereby affirm that all of the information presented in this application is true
				and correct.
____________________________
				___________________
(Signature)(Date)
Please mail completed application to:
Illinois Department of Insurance
Utilization Review Unit
320 West Washington Street
Springfield IL 62767-000
1(217) 558-2309