Iowa Admin. Code r. 191 app E
1. BASIC INFORMATION:
Name:
Street Address:
City, State, ZIP:
Telephone (a toll-free telephone service to receive information related to external reviews 24 hours a day, 7 days a week, that is capable of accepting, recording, or providing appropriate instruction to incoming telephone callers outside normal business hours):
Fax Number:
Email Address:
Director, Officer, or Executive Officer responsible for supervision and oversight of review procedures:
Telephone:
Fax Number:
Email Address:
Contact person to receive contacts, notices, and information from the Division:
Telephone:
Fax Number:
Email Address:
2. Names and titles of all directors, officers, and executives:
3. Identify independent review accreditation by nationally recognized private accrediting entity:
4. Identify all clinical reviewers to be assigned by your IRO by name, general certification, and specialty or subspecialty certification:
A clinical reviewer shall be a physician or other appropriate health care professional who is an expert in the treatment of the covered person's medical condition, is knowledgeable about the recommended or requested health care service or treatment through actual clinical experience treating patients with the same or similar medical condition, 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, and has no history of disciplinary actions or sanctions.
5. I, ____________________(authorized signatory), agree to the following undertakings and have provided attachments as required:
a. To provide notices and conduct reviews within the specified time frames.
b. To ensure the selection of qualified and impartial clinical reviewers and suitable matching of reviewers to specific cases.
c. To ensure the confidentiality of medical and treatment records and clinical review criteria.
d. To establish and maintain written procedures to ensure the IRO is unbiased.
Specifically, the IRO 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. Further, neither the independent review organization 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 the health carrier, the covered person or covered person's representative, any officer, director, or management employee of the health carrier, the health care professional, 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, the facility at which the recommended health care service or treatment would be provided, the developer or manufacturer of the principal drug, device, procedure, or other therapy being recommended for the covered person whose health care service or treatment is the subject of the external review.
e. To maintain required records and provide access to those records by the commissioner upon request.
6. Set forth a description of fees to be charged by the independent review organization for external reviews.
Iowa Admin. Code r. 191 app E