Idaho External Review Requirements for Independent Review Organizations
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 is available as follows:
- Idaho Code, Title 41, Chapter 59 - Idaho Health Carrier External Review Act
- IDAPA 18.01.05 - Health Carrier External Review, Idaho ules 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
IROs must comply with Idaho requirements for:
- Approval of IROs -- §41-5911
- Standard external reviews -- §41-5908
- Expedited external reviews -- §41-5909
- Reporting and record retention -- §41-5914
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.
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.