Iowa Administrative Code › Agency 191 - Insurance Division › Life and Health Insurance › Chapter 39 - Long-term Care Insurance › Rule 191-39.52 - Certification of Independent Review Entity

Current through Register Vol. 47, No. 3, July 24, 2024
The following minimum standards are required for
				  certification as an independent review entity:
(1) The entity shall ensure that any licensed
				health care professional on its staff who participates in an independent review
				proceeding holds a current unrestricted license or certification to practice a
				health care profession in the United States.
(2) The entity shall ensure that any licensed
				health care professional on its staff who participates in an independent review
				proceeding and who is a physician holds a current certification by a recognized
				American medical specialty board in a specialty appropriate for determining an
				insured's functional or cognitive impairment.
(3) The entity shall ensure that any licensed
				health care professional on its staff who participates in an independent review
				proceeding and who is not a physician holds a current certification in the
				specialty in which that person is licensed by a recognized American specialty
				board in a specialty appropriate for determining an insured's functional or
				cognitive impairment.
(4) The
				entity shall ensure that any licensed health care professionals on its staff
				who participate in an independent review proceeding have no history of
				disciplinary actions or sanctions including, but not limited to, the loss of
				staff privileges or any participation restriction taken or pending by any
				hospital or state or federal government regulatory agency for wrongdoing by the
				health care professional.
(5) The
				entity shall ensure that neither the entity, nor any of its employees, agents,
				or licensed health care professionals utilized, receive compensation of any
				type that is dependent on the outcome of the review.
(6) The entity shall ensure that neither the
				entity, nor any of its employees, agents, or licensed health care professionals
				utilized, are in any manner related to, employed by, or affiliated with the
				insured or with a person who previously provided medical care to the
				insured.
(7) The entity shall
				provide a description of the qualifications of the reviewers retained to
				conduct independent review of long-term care insurance benefit trigger
				decisions, including the reviewers' employment histories and practice
				affiliations for at least the prior ten years, and a description of past
				experience with decisions relating to long-term care, functional capacity, and
				dependency in activities of daily living, or in assessing cognitive
				impairment.
(8) The entity shall
				provide a description of the procedures employed to ensure that reviewers
				conducting independent reviews are appropriately: licensed, registered or
				certified; trained in the principles, procedures and standards of the
				independent review entity; knowledgeable about the functional or cognitive
				impairments associated with the diagnosis and disease staging processes,
				including expected duration of such impairment; and knowledgeable and
				experienced in diagnosing a person as a "chronically ill individual" as defined
				in Section 7702B(c)(2) of the Internal Revenue Code.
(9) The entity shall provide a description of
				the evaluation tools the entity would use to conduct a review of a long-term
				care insurance benefit trigger decision.
(10) The entity shall provide a description
				of the methods of recruiting and selecting impartial reviewers and matching
				such reviewers to specific cases.
(11) The entity shall provide the number of
				reviewers retained by the independent review entity and a description of the
				areas of expertise available from such reviewers and the types of cases such
				reviewers are qualified to review (e.g., assessment of cognitive impairment or
				inability to perform activities of daily living due to a loss of functional
				capacity).
(12) The entity shall
				provide a description of the policies and procedures employed to protect
				confidentiality of individual personally identifiable health information in
				accordance with applicable state and federal laws.
(13) The entity shall provide a description
				of the quality assurance program established by the independent review
				entity.
(14) The entity shall
				provide the names of all corporations and organizations owned or controlled by
				the independent review entity or which own or control the entity, and the
				nature and extent of any such ownership or control. The entity must ensure that
				neither the entity, nor any of its employees, agents, or licensed health care
				professionals utilized, are a subsidiary of, or owned or controlled by, an
				insurer or by a trade association of insurers of which the insurer is a
				member
(15) The entity shall
				provide the names and resumes of all directors, officers and executives of the
				entity.
(16) The entity shall
				provide a description of the fees to be charged by the entity for independent
				reviews of a long-term care insurance benefit trigger decision.
(17) The entity shall provide the name of the
				medical director or health professional director responsible for the
				supervision and oversight of the independent review procedure.
(18) The entity must have on staff or
				contract with a licensed health care practitioner who is qualified to certify
				that an individual is chronically ill for purposes of a qualified long-term
				care insurance contract.