§ 514J.112 — Minimum qualifications for independent review organizations

Iowa § 514J.112

• Jurisdiction: Iowa
• Title XIII: COMMERCE
• Ch. 514J: EXTERNAL REVIEW OF HEALTH CARE COVERAGE DECISIONS

Text

1. To be approved to conduct external reviews pursuant to this chapter, an independent
review organization shall have and maintain written policies and procedures that govern
all aspects of both the standard external review process and the expedited external review
process and that include, at a minimum, all of the following:
a. A quality assurance mechanism that does all of the following:
(1) Ensures that external reviews are conducted within the specified time frames and that
required notices are provided in a timely manner.
(2) Ensures the selection of qualified and impartial clinical reviewers to conduct external
reviews on behalf of the independent review organization and suitable matching of reviewers
to specific cases and that the independent review organization employs or contracts with an
adequate number of clinical reviewers to meet this objective.
(3) Ensures the confidentiality of medical and treatment records and clinical review
criteria.
(4) Establishes and maintains written procedures to ensure that the independent review
organization is unbiased in addition to any other procedures required under this section.
(5) Ensures that any person employed by or under contract with the independent review
organization adheres to the requirements of this chapter.
b. A toll-free telephone service to receive information related to external reviews
twenty-four hours a day, seven days a week, that is capable of accepting, recording, or
providing appropriate instruction to incoming telephone callers outside normal business
hours.
17 EXTERNAL REVIEW OF HEALTH CARE COVERAGE DECISIONS, §514J.112
c. An agreement and a system to maintain required records and provide access to those
records by the commissioner.
2. Each clinical reviewer assigned by an independent review organization to conduct
external reviews shall be a physician or other appropriate health care professional who
meets all of the following minimum qualifications:
a. Is an expert in the treatment of the covered person’s medical condition that is the
subject of the external review.
b. Isknowledgeableabouttherecommendedorrequestedhealthcareserviceortreatment
through recent or current actual clinical experience treating patients with the same or similar
medical condition as the covered person.
c. Holds 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 or areas
appropriate to the subject of the external review.
d. Has 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
agencyorunit,orregulatorybodythatraiseasubstantialquestionastotheclinicalreviewer’s
physical, mental, or professional competence or moral character.
3. An independent review organization shall 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.
4. Neither the independent review organization selected to conduct an external review
nor any clinical reviewer assigned by the independent organization to conduct an external
review shall have a material professional, familial, or financial conflict of interest with any of
the following:
a. The health carrier that is the subject of the external review.
b. Thecoveredpersonwhosehealthcareserviceortreatmentisthesubjectoftheexternal
review or the covered person’s authorized representative.
c. Any officer, director, or management employee of the health carrier that is the subject
of the external review.
d. The health care professional or the health care professional’s medical group or
independent practice association recommending the health care service or treatment that
is the subject of the external review.
e. The facility at which the recommended health care service or treatment would be
provided.
f. Thedeveloperormanufactureroftheprincipaldrug,device,procedure,orothertherapy
beingrecommendedforthecoveredpersonwhosehealthcareservicetreatmentisthesubject
of the external review.
5. In determining whether an independent review organization or a clinical reviewer
of the independent review organization has a material professional, familial, or financial
conflictofinterestasprovidedinsubsection4, thecommissionershalltakeintoconsideration
situations where the independent review organization to be assigned to conduct an external
review of a specified case or a clinical reviewer to be assigned by the independent review
organization to conduct an external review of a specified case may have an apparent
professional, familial, or financial relationship or connection with a person described in
subsection 4, but the characteristics of that relationship or connection are such that they do
not constitute a material professional, familial, or financial conflict of interest that would
prohibit selection of the independent review organization or the clinical reviewer to conduct
the external review.
6. a. An independent review organization that is accredited by a nationally recognized
private accrediting entity that has independent review accreditation standards that the
commissioner has determined are equivalent to or exceed the minimum qualifications of
this section shall be presumed to be in compliance with the requirements of this section.
b. The commissioner shall initially and periodically review the standards of each
nationally recognized private accrediting entity that provides accreditation to independent
review organizations to determine whether the accrediting entity’s standards are, and
§514J.112, EXTERNAL REVIEW OF HEALTH CARE COVERAGE DECISIONS 18
continue to be, equivalent to or exceed the minimum qualifications established under
this section. The commissioner may accept a review of those standards conducted by the
national association of insurance commissioners for the purpose of making a determination
under this subsection.
c. Upon request, a nationally recognized private accrediting entity shall make its current
independent review organization accreditation standards available to the commissioner or
to the national association of insurance commissioners in order for the commissioner to
determine if the accrediting entity’s standards are equivalent to or exceed the minimum
qualifications established under this section. The commissioner may exclude consideration
of accreditation of independent review organizations by any private accrediting entity whose
standards have not been reviewed by the national association of insurance commissioners.