§ 27-8-29-19 — Annual certifications of independent review organizations

(a) The department shall establish and
maintain a process for annual certification of independent review
organizations.
(b) The department shall certify a number of independent review
organizations determined by the department to be sufficient to fulfill
the purposes of this chapter.
(c) An independent review organization must meet the following
minimum requirements for certification by the department:
(1) Medical review professionals assigned by the independent
review organization to perform external grievance reviews under
this chapter:
(A) must be board certified in the specialty in which a covered
individual's proposed service would be provided;
(B) must be knowledgeable about a proposed service through
actual clinical experience;
(C) must hold an unlimited license to practice in a state of the
United States; and
(D) must not have any history of disciplinary actions or
sanctions, including:
(i) loss of staff privileges; or
(ii) restriction on participation;
taken or pending by any hospital, government, or regulatory
body.
(2) The independent review organization must have a quality
assurance mechanism to ensure:
(A) the timeliness and quality of reviews;
(B) the qualifications and independence of medical review
professionals;
(C) the confidentiality of medical records and other review
materials; and
(D) the satisfaction of covered individuals with the procedures
utilized by the independent review organization, including the
use of covered individual satisfaction surveys.
(3) The independent review organization must file with the
department the following information on or before March 1 of
each year:
(A) The number and percentage of determinations made in
favor of covered individuals.
(B) The number and percentage of determinations made in
favor of insurers.
(C) The average time to process a determination.
(D) The number of external grievance reviews terminated due
to reconsideration of the insurer before a determination was
made.
(E) Any other information required by the department.
The information required under this subdivision must be specified
for each insurer for which the independent review organization
performed reviews during the reporting year.
(4) The independent review organization must retain all records
related to an external grievance review for at least three (3) years
after a determination is made under section 15 of this chapter.
(5) Any additional requirements established by the department.
(d) The department may not certify an independent review
organization that is one (1) of the following:
(1) A professional or trade association of health care providers or
a subsidiary or an affiliate of a professional or trade association
of health care providers.
(2) An insurer, a health maintenance organization, or a health
plan association, or a subsidiary or an affiliate of an insurer,
health maintenance organization, or health plan association.
(e) The department may suspend or revoke an independent review
organization's certification if the department finds that the independent
review organization is not in substantial compliance with the
certification requirements under this section.
(f) The department shall make available to insurers a list of all
certified independent review organizations.
(g) The department shall make the information provided to the
department under subsection (c)(3) available to the public in a format
that does not identify individual covered individuals.

Legislative History

As added by P.L.66-2001, SEC.3 and P.L.203-2001, SEC.14. Amended by P.L.1-2002, SEC.121; P.L.160-2011, SEC.25.