The Idaho Health Carrier External Review Act took effect on January 1, 2010. The Act provides a covered person the
right to have a health claim denial reviewed by an independent review organization (IRO) if the denial is based on the
health carrier’s requirements for medical necessity, appropriateness, health care setting, level of care, effectiveness
or is determined to be investigational.
Information regarding this act
IROs must comply with Idaho requirements
Minimum IRO Qualifications (§41-5912)
Written Policies and Procedures
To be approved to conduct external reviews for Idaho, an IRO must have and maintain
written policies and procedures that govern all aspects of both the standard and expedited review process under Idaho’s
Health Carrier External Review Act. These policies and procedures must include at a minimum:
- A quality assurance mechanism in place that:
- Ensures external reviews are conducted within the specified time frames and required notices are provided in a
timely manner;
- Ensures the 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 IRO employs or contracts with an adequate
number of clinical reviewers to meet this objective;
- Ensures the confidentiality of medical and treatment records and clinical review criteria; and
- Ensures that any person employed by or under contract with the IRO adheres to the requirements of Idaho’s
laws;
- A toll-free telephone service to receive information on a 24-hour day, 7 days a week basis for external reviews
that is capable of accepting, recording or providing appropriate instruction to incoming callers during other than
normal business hours;
- An agreement to maintain and provide to our Department any information required by
§ 41-5914 and
rule IDAPA 18.01.05.
Clinical Reviewers
All clinical reviewers assigned by an IRO to conduct external reviews must be physicians
or other appropriate health care providers who meet all the following minimum qualifications:
- Be an expert in the treatment of the covered person’s medical condition that is the subject of the external
review;
- 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 of the covered person;
- Hold 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(s) appropriate to the subject of the external review; and
- 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.
Conflict of Interest
An IRO 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.
Neither the IRO selected to conduct an external review, nor any clinical reviewer assigned by the IRO to conduct an
external review, may have a material professional, familial or financial conflict of interest with any of the following:
- The health carrier that is the subject of the external review;
- The covered person whose treatment is the subject of the external review;
- 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.
In determining if an IRO or clinical reviewer has a conflict of interest, our Department will take into consideration
situations where the IRO or clinical reviewer has an apparent conflict of interest, but the characteristics of the
relationship are not a material conflict of interest that would cause disapproval of the IRO or clinical reviewer to
conduct a review.
Accreditation
An IRO accredited by a nationally recognized private accrediting entity that meets our Department’s standards, such as
URAC, will be presumed to be eligible for approval under Idaho’s laws.
Funding for External Review
The health carrier against which an external review request is filed must pay the costs of the IRO conducting the
external review. An IRO must include its schedule of costs and fees as part of its Idaho application. Any subsequent
changes to an IRO’s costs and fees schedule must be submitted to our Department at least 60 days prior to the effective
date of the change. The change in costs and fees may not be applied to an external review being performed at the time of
change.
Termination of IRO
Approval: An IRO must notify our Department in writing within 30 days of the date the IRO is no longer accredited by
URAC or can no longer satisfy the requirements under Idaho’s External Review laws. Our Department will immediately
terminate the IRO’s approval upon notice that the IRO is no longer accredited, or upon determination that the IRO
otherwise no longer satisfies Idaho’s requirements. Our Department will notify the IRO of termination in writing. The
IRO must stop any external review being performed at the time of termination and immediately forward all information
and documentation to our Department.
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