(1)To be approved under section 44-1312 to conduct external reviews, 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 set forth in the Health Carrier External
Review Act that include, at a minimum:
(a)A quality assurance
mechanism in place that:
(i)Ensures that external reviews are conducted within the specified timeframes
and that required notices are provided in a timely manner;
(ii)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
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(1)
To be approved under section 44-1312 to conduct external reviews, 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 set forth in the Health Carrier External
Review Act that include, at a minimum:
(a) A quality assurance
mechanism in place that:
(i)
Ensures that external reviews are conducted within the specified timeframes
and that required notices are provided in a timely manner;
(ii) 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;
(iii) Ensures the confidentiality
of medical and treatment records and clinical review criteria; and
(iv) Ensures that any
person employed by or under contract with the independent review organization
adheres to the requirements of the act;
(b) A toll-free telephone service to receive information
on a twenty-four-hours-per-day, seven-days-per-week basis related to external
reviews that is capable of accepting, recording, or providing appropriate
instruction to incoming telephone callers during other than normal business
hours; and
(c)
An agreement to maintain and provide to the director the information set out
in section 44-1315 .
(2)
All clinical reviewers assigned by an independent review organization to conduct
external reviews shall be physicians or other appropriate health care providers
who meet the following minimum qualifications:
(a) Be an expert in the treatment
of the covered person's medical condition that is the subject of the external
review;
(b)
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;
(c) Hold a nonrestricted license
in a state of the United States and, for physicians, a current certification
by a recognized medical specialty board in the United States in the area or
areas appropriate to the subject of the external review; and
(d) 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.
(3)
In addition to the requirements set forth in subsection (1) of this section,
an independent review organization may not own or control, be a subsidiary
of, 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)(a) In addition to
the requirements set forth in subsections (1), (2), and (3) of this section,
to be approved pursuant to section 44-1312 to conduct an external review of
a specified case, neither the independent review organization selected to
conduct the external review nor any clinical reviewer assigned by the independent
review organization to conduct the external review may have a material professional,
familial, or financial conflict of interest with any of the following:
(i) The health carrier
that is the subject of the external review;
(ii) The covered person whose treatment is the subject
of the external review or the covered person's authorized representative,
if applicable;
(iii)
Any officer, director, or management employee of the health carrier that is
the subject of the external review;
(iv) The health care provider or 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;
(v) The facility at which
the recommended health care service or treatment would be provided; or
(vi) 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.
(b)
In determining whether an independent review organization or a clinical reviewer
of the independent review organization has a material professional, familial,
or financial conflict of interest for purposes of subdivision (4)(a) of this
section, the director shall take into consideration situations in which 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 subdivision (4)(a) of this section, but that the
characteristics of that relationship or connection are such that they are
not a material professional, familial, or financial conflict of interest that
results in the disapproval of the independent review organization or the clinical
reviewer from conducting the external review.
(5)(a) An independent review organization
that is accredited by a nationally recognized private accrediting entity that
has independent review accreditation standards that the director has determined
are equivalent to or exceed the minimum qualifications of this section shall
be presumed in compliance with this section to be eligible for approval under
section 44-1312 .
(b)
The director 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 established under
this section. The director may accept a review conducted by the National Association
of Insurance Commissioners for the purpose of the determination under this
subdivision.
(c)
Upon request, a nationally recognized private accrediting entity shall make
its current independent review organization accreditation standards available
to the director or the National Association of Insurance Commissioners in
order for the director to determine if the entity's standards are equivalent
to or exceed the minimum qualifications established under this section. The
director may exclude any private accrediting entity that is not reviewed by
the National Association of Insurance Commissioners.
(6) 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 under this section.