Iowa Administrative Code › Agency 191 - Insurance Division › Health Benefit Plans › Chapter 76 - External Review › Appendix E - Independent Review Organization Application

Current through Register Vol. 47, No. 3, July 24, 2024
1. BASIC INFORMATION:
Name:
Street Address:
City, State, ZIP:
Telephone (a toll-free telephone service to receive
				  information related to external reviews 24 hours a day, 7 days a week, that is
				  capable of accepting, recording, or providing appropriate instruction to
				  incoming telephone callers outside normal business hours):
Fax Number:
Email Address:
Director, Officer, or Executive Officer responsible for
				  supervision and oversight of review procedures:
Telephone:
Fax Number:
Email Address:
Contact person to receive contacts, notices, and information
				  from the Division:
Telephone:
Fax Number:
Email Address:
2. Names and titles of all directors, officers, and
				  executives:
3. Identify independent review accreditation by nationally
				  recognized private accrediting entity:
4. Identify all clinical reviewers to be assigned by your IRO
				  by name, general certification, and specialty or subspecialty
				  certification:
A clinical reviewer shall be a physician or other appropriate
				  health care professional who is an expert in the treatment of the covered
				  person's medical condition, is knowledgeable about the recommended or requested
				  health care service or treatment through actual clinical experience treating
				  patients with the same or similar medical condition, holds a nonrestricted
				  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 has no history of
				  disciplinary actions or sanctions.
5. I, ____________________(authorized signatory), agree to
				  the following undertakings and have provided attachments as required:
a. To provide notices and conduct reviews within the
				  specified time frames.
b. To ensure the selection of qualified and impartial
				  clinical reviewers and suitable matching of reviewers to specific cases.
c. To ensure the confidentiality of medical and treatment
				  records and clinical review criteria.
d. To establish and maintain written procedures to ensure the
				  IRO is unbiased.
Specifically, the IRO shall 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. Further, neither the independent review organization nor
				  any clinical reviewer assigned by the independent organization to conduct an
				  external review shall have a material professional, familial, or financial
				  conflict of interest with the health carrier, the covered person or covered
				  person's representative, any officer, director, or management employee of the
				  health carrier, the health care professional, the health care professional's
				  medical group or independent practice association recommending the health care
				  service or treatment that is the subject of the external review, the facility
				  at which the recommended health care service or treatment would be provided,
				  the developer or manufacturer of the principal drug, device, procedure, or
				  other therapy being recommended for the covered person whose health care
				  service or treatment is the subject of the external review.
e. To maintain required records and provide access to those
				  records by the commissioner upon request.
6. Set forth a description of fees to be charged by the
				  independent review organization for external reviews.