§ 22:2441 — Minimum qualifications for independent review organizations

§2441. Minimum qualifications for independent review organizations
A. To be approved under R.S. 22:2440 to conduct external reviews, an independent
review organization shall not be a health insurance issuer and 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 provided for in this Part. At a minimum, these
shall include the following:
(1) A quality assurance mechanism in place that:
(a) Ensures that external reviews are conducted within the specified time frames and
required notices are provided in a timely manner.
(b) Ensures the selection of qualified and impartial clinical peers to conduct external
reviews on behalf of the independent review organization and suitable matching of peers to
specific cases and ensures that the independent review organization employs or contracts
with an adequate number of clinical peers to meet this objective.
(c) Ensures the confidentiality of medical and treatment records and clinical review
criteria.
(d) Ensures that any person employed by or under contract with the independent
review organization adheres to the requirements of this Part.
(2) A toll-free telephone service to receive information on a twenty-four-hour-a-day,
seven-day-a-week basis related to external reviews that is capable of accepting, recording,
or providing appropriate instructions to incoming telephone callers during other than normal
business hours.
(3) An agreement to maintain and provide to the commissioner the information
required pursuant to R.S. 22:2443.
B. Any clinical peer assigned by an independent review organization to conduct
external reviews shall be a physician or other appropriate health care provider who meets the
following minimum qualifications:
(1) Is an expert in the treatment of the covered person's medical condition that is the
subject of the external review.
(2) Is 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.
(3) Has a nonrestrictive medical 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.
(4) Does not have a 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 peer's physical, mental, or professional competence or moral character.
C. In addition to the requirements specified in Subsection A of this Section, 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.
D.(1) In addition to the requirements specified in Subsections A, B, and C of this
Section, in order to be approved pursuant to R.S. 22:2440 to conduct an external review of
a specified case, neither the independent review organization selected to conduct the external
review nor any clinical peer assigned by the independent organization to conduct the external
review may have a material professional, familial, or financial conflict of interest with any
of the following:
(a) The health insurance issuer that is the subject of the external review.
(b) The covered person whose treatment is the subject of the external review or his
authorized representative.
(c) Any officer, director, or management employee of the health insurance issuer that
is the subject of the external review.
(d) The health care provider, his medical group, or his 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) 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.
(2) In determining whether an independent review organization or a clinical peer of
the independent review organization has a material professional, familial, or financial
conflict of interest for purposes of Paragraph (1) of this Subsection, the commissioner shall
take into consideration situations in which the independent review organization or clinical
peer to be assigned by the independent review organization to conduct an external review of
a specified case may have such a relationship or connection with a person specified in
Paragraph (1) of this Subsection, but that the characteristics of such relationship or
connection are not a material conflict of interest that would result in the disapproval of the
independent review organization or the clinical peer from conducting the external review.
E.(1) 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 in compliance with this Section and be eligible for approval
pursuant to R.S. 22:2440. An independent review organization submitting proof of
accreditation in support of an application for approval shall immediately inform the
commissioner of any subsequent loss, revocation, or other material change to any
accreditation.
(2) The commissioner shall initially review and periodically review the independent
review organization accreditation standards of a nationally recognized private accrediting
entity to determine whether the entity's standards are, and continue to be, equivalent to or
exceed the minimum qualifications provided for in this Section.
(3) Upon request, a nationally recognized private accrediting entity shall make its
current independent review organization accreditation standards available to the
commissioner in order for the commissioner to determine if the entity's standards are
equivalent to or exceed the minimum qualifications provided for in this Section.
F. An independent review organization shall be unbiased. An independent review
organization shall establish and maintain written procedures to ensure that it is unbiased in
addition to any other procedures required by this Section.

Legislative History

Acts 2013, No. 326, §1, eff. Jan. 1, 2015; Acts 2017, No. 14, §1.