Independent Review Organization 

An Independent Review Organization is a business entity that conducts an independent external review of an adverse determination.

Note:  The NRS refer to an Independent Review Organization, yet the NAC refers to an External Review Organization.  The Division of Insurance (Division) uses both terms interchangeably.  For the purposes of this page, Independent Review Organization will be used.

Approval Required

An Independent Review Organization must be approved by the Division prior to being assigned to conduct external reviews.

In order to be eligible for approval, an Independent Review Organization must:

• Be accredited by a nationally recognized private accrediting entity which has been deemed to meet or exceed the minimum qualifications established under NRS 683A.372;  
• Maintain written policies and procedures that govern all aspects of both the standard external review process and the expedited external review process as required by NRS 683A.372; 
• Have assigned a clinical reviewer who is a physician or other appropriate health care provider; and 
• Not own or control, be a subsidiary of or in any way 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; 

In addition to the above requirements, neither the Independent Review Organization nor the clinical reviewer may have any material professional, familial, or financial conflict of interest with:

• The health carrier that is the subject of the external review; 
• The covered person whose treatment is the subject of the external review or the covered person’s authorized representative; 
• Any officer, director or management employee of the health carrier that is the subject of the external review; 
• 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; 
• The facility at which the recommended health care service or treatment would be provided; or 
• 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. 

Certificate Term

• Two years from date of issuance;
• Until accreditation is lost or the minimum qualifications are no longer met; or
• Until certificate is refused, revoked or suspended by the Division.

How to Apply

An applicant for a certificate as an Independent Review Organization must:

• Submit a paper application to the Division’s Carson City Office;
• Submit the written statement, the written summary of procedures, and the written affidavit required by NAC 683A.600; and
• Remit payment of: 
      * If conducting external reviews pursuant to NRS 683A only - $400
      * If conducting external reviews pursuant to NRS 683A and 616A - $600
      * All applicable fees pursuant to NRS 680C.110 - $60  

In addition to the above requirements, Independent Review Organizations that are accredited by a nationally recognized private accrediting entity must:

• Submit proof of certification or accreditation;
• Submit a copy of the certification or accreditation standards of the accrediting body;
• Submit a copy of the most recent review of the external review organization conducted by the accrediting body; and
• Submit the schedule of fees that the external review organization will charge to conduct an external review.   

Payments may be made by check, money order, or Electronic Funds Transfer (EFT).  Please make checks and money orders payable to the Nevada Division of Insurance.  Please contact the Accounting Section at ifn@doi.nv.gov to request the required EFT form.

How to Renew

A certificate is valid for two years after issuance and expires on the two-year anniversary date. Certificates must be renewed on Sircon.com and the renewal fee is $160. There is no late fee period; failure to renew by the two-year anniversary date will result in the certificate being inactivated and the organization will need to reapply.  

Legal Authority

Independent review organizations are governed by the provisions of Nevada Revised Statutes (NRS) 616A, 683A, 695G and the corresponding chapters of the Nevada Administrative Code.