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Independent Review Organization

INSTRUCTIONS FOR INDEPENDENT REVIEW ORGANIZATIONS THAT ARE NOT CERTIFIED OR ACCREDITED

A completed application and the following information:

  1. The number of external reviewers that the IRO employees, contracts with or otherwise retains, the specialty of each external reviewer and whether the reviewer is certified by the entity that regulates his specialty.
  2. Schedule of fees charged for external reviews.
  3. A written summary of procedures that the IRO will use to:
    • Ensure that the IRO conducts it’s activities in accordance with the statute;
    • Ensure that an external reviewer employed, contracted with or otherwise retained by the IRO is qualified to conduct a specific review;
    • Ensure that a determination submitted for external review is a final adverse determination
    • Ensure that a final review is conducted in a timely manner
    • Ensure that the IRO and any employee, agent or contractor of the IRO does not have a conflict of interest as set forth in the statute.
    • Ensure that a copy of the determination regarding an external review is provided to the insured, the physician of the insured, the authorized representative to the insured (if any) and the managed care organization.
  4. Written affidavit certified by an officer of the entity stating:
    • The information contained in the application and accompanying materials are complete
    • The external review organization will conduct external reviews in accordance with the statute.
    • The IRO and any employees, agent or contractor of the IRO will avoid a conflict of interest.
    • The IRO is not affiliated with a health care plan or a national, state or local trade association.
  5. $460.00 Fee for the Certificate

INSTRUCTIONS FOR EXTERNAL REVIEW ORGANIZATIONS THAT ARE CERTIFIED OR ACCREDITED

A completed application and the following information:

  1. Proof that the external review organization has been certified or accredited as an external review organization by an accrediting body that is nationally recognized.
  2. Copy of the certification or accreditation standards of the accrediting body.
  3. Copy of most recent review of the IRO conducted by the accrediting body.
  4. Schedule of fees charged for external reviews.
  5. $460.00 Fee for the Certificate

If an applicant is applying at the same time for both a Health and Workers Compensation External Review certificate the fee is $660 for both certificates.

Registration for renewal of IRO must be made one year after the date the certificate is issued on a form prescribed by the Commissioner with applicable fee.