Independent Review Organization

Idaho Code, Title 41, Chapter 59*- Idaho Health Carrier External Review Act

IDAPA 18.04.01 – Health Carrier External Review, Idaho Rules for the External Review Act.

Bulletin 09-08*- Idaho Health Carrier External Review Act, dated August 20, 2009

Bulletin 11-04 *- Idaho Health Carrier External Review Act Amendments, dated June 13, 2011

Approval of IROs — §41-5911

Standard external reviews — §41-5908

Expedited external reviews — §41-5909

Reporting and record retention — §41-5914

Independent Review Organization: an entity that conducts independent external reviews of final adverse benefit determinations.

For a full list of insurance licensing terms please click here.

To act as an IRO an organization must be accredited by URAC, a nationally recognized private accrediting entity, and approved by the Idaho Department of Insurance. To become approved, the organization must submit an application to the Department. A notice of the application will be published on the Department’s website for a period of 42 days to provide an opportunity for public comment.

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 ensure:
  • external reviews are conducted within the specified time frames and required notices are provided in a timely manner;
  • 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;
  • the confidentiality of medical and treatment records and clinical review criteria; and
• 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.

To apply for an Independent Review Organization you will need to assemble an application packet. This packet consists of the following items.

• Paper Application
• Copy of URAC accreditation
• Certified statement that IRO will not be operated by health benefit plan and confirmation of compliance with 41-5912(3) regarding ownership and control of applicant
• Chart to show internal structure of applicant’s management and administrative staff (see application for specific criteria for this chart)
• Fee Schedule for IRO
• Descriptions of areas of expertise
• Number of clinical reviewers per specialty
• Description of quality assurance mechanisms
• Non-Refundable Application Fee: $500. Checks should be made payable to the Idaho Department of Insurance

Once all items have been compiled send the application packet to:

Idaho Department of Insurance
700 W State Street, 3rd Floor
PO Box 83720
Boise ID 83720-0043

Pursuant to Idaho statutes a notice of application for licensure as an IRO is posted to the Departments website upon receipt for public comment. Any members of the public who wish to respond to an application noted below shall submit written comments to the attention of:

Lori Thomason, Producer Licensing
Idaho Department of Insurance
700 W State St., Third Floor
PO Box 83720
Boise, ID 83720

Responses shall be received by the due date noted below. Please include specific details regarding any objections to an application.

The director may not take final action on the application until at least forty-two (42) days after posting the required notice.

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.
• 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.

Be an IRO accredited by a nationally recognized private accrediting entity that meets the Department’s standards, such as URAC, will be presumed to be eligible for approval under

An IRO must notify the 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. The 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.  The 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 the Department.

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 the 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.

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 the 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.

Independent Review Organization licenses renew every two years from the date of issue.

A renewal can be applied for up to six weeks prior to the expiration of the license.

The Department considers the renewal of the license to be the responsibility of the licensee.

Please contact the Department, 208-334-4339 if special arrangements need to be made.

Renewal Checklist

• Mail in renewal form
• A copy of your current URAC Certificate.
• Non-Refundable $300 renewal fee. Checks should be made payable to the Idaho Department of Insurance.

The renewal form and attachments should be mailed to:

Idaho Department of Insurance
700 W State Street, 3rd Floor
PO Box 83720
Boise ID 83720-0043

A license copy will be emailed to you upon approval. Be sure you have provided a current email address.

Reinstatement of an IRO license is available for up to 1 year after the expiration of the license.

Please contact the Department, 208-334-4339 if special arrangements need to be made.

Reinstatement Checklist

• Reinstatement Form
• Copy of the current URAC Certificate.
• Non-Refundable $600 reinstatement fee. Checks should be made payable to the Idaho Department of Insurance.

The reinstatement form and attachments should be mailed to:

Idaho Department of Insurance
700 W State Street, 3rd Floor
PO Box 83720
Boise ID 83720-0043

Be sure to provide a current email address as a license copy will be emailed upon approval.

The following independent review organizations (IROs) have met the requirements under the Idaho Health Carrier External Review Act in Idaho Code Title 41, Chapter 59. These IROs are accredited by URAC.

The Idaho Health Carrier External Review Act provides covered persons the right to have a health claim denial reviewed by an 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. External review requests are coordinated through the Consumer Affairs section in the Department of Insurance.

ADVANCED MEDICAL REVIEWS INC

BHM HEALTHCARE SOLUTIONS INC.
C2C INNOVATIVE SOLUTIONS, INC
CLAIMS EVAL, INC
COREVISORY
EDIPHY ADVISORS, LLC
FEDERAL HEARINGS AND APPEALS SERVICES, INC
INDEPENDENT MEDICAL EXPERT CONSULTING SERVICES INC DBA:
MAXIMUS FEDERAL SERVICES, INC
MCMC SERVICES LLC
MITCHELL INTERNATIONAL INC DBA:
NATIONAL MEDICAL REVIEWS, INC
NETWORK MEDICAL REVIEW COMPANY LTD
PHYSICIANS REVIEW ORGANIZATION, INC
PROPEER RESOURCES LLC
ROFFE ENTERPRISES, INC DBA:

Producers and agencies have a duty to report any criminal or administrative actions to the Idaho Department of Insurance within 30 days per §41-1021.

Producers are encouraged to use the NIPR Reporting of Actions Warehouse at www.nipr.com as a convenient means to post documents and explanations related to reportable actions.

While the Department encourage the use of the NIPR Reporting of Actions Warehouse for documents, actions still need to be reported to the Department directly, either by e-mail or the applicable background question on new license applications and/or renewals.

Links

Update Contact Information

Printable Forms

Application Form, Independent Review Organization

IRO Checklist

IRO License Flyer

Name Change, Business

Renewal Form, Independent Review Organization

Reinstatement Form, Independent Review Organization

Update Address Form, State to State