N.H. Admin. Code § Ins 2703.07

Current through Register No. 36, September 5, 2024

Section Ins 2703.07 - Certification of Independent Review Organizations

(a) The certification of independent review organizations shall be conducted as follows:

(1) An independent review organization seeking certification shall supply the following information:

a. Name, address and telephone number of the organization;

b. The name, address, and telephone number of the chief executive officer;

c. The tax status and federal employer tax identification number;

d. The list of states where the organization is incorporated, licensed, certified, or otherwise authorized to conduct business;

e. A description of the organizational structure that identifies and explains the lines of authority within the organization itself and if applicable within a holding company or parent subsidiary system;

f. A description of the management of the organization, including the files and management responsibilities of the staff;

g. A description of the contracted service providers and clinical peer reviewers, as well as a description of the procedures used to ensure the adequacy of the network of clinical peer reviewers retained by the organization and the procedures used to ensure that the peer reviewers are adequately trained and appropriately licensed;

h. A list of all reviewers in the clinical peer review network including the name, license number and clinical discipline of each reviewer;

i. A description and copy of the quality assurance program established by the organizations, which specifically address the policies and procedures used to protect the confidentiality of medical and treatment records;

j. The name of the medical director, and a description of the medical director's qualifications;

k. A description of the procedures that will be used to ensure that standard and expedited appeals are conducted within the required time frames;

l. A description of the current financial status of the organization, including the most recent certified financial statement;

m. A list of fees that will be charged for independent review and an explanation of the methodology used to develop the fee schedule;

n. A conflict of interest attestation signed by each owner, officer, director, medical director or management employee of the applicant, which shall be supported by personal information including the name, address, telephone number, and the person's 10 year employment history;

o. A statement verifying that any person subject to the requirement of filing a conflict of interest attestation has submitted a report of his/her history of legal actions, as well as a report of his/her affiliation with other health care corporations; and

p. Evidence of accreditation by a nationally recognized private accrediting entity with established and maintained standards for independent review organizations.

(2) The application shall be signed by the chief executive officer and the board chairman who shall attest to its accuracy;

(3) The commissioner shall maintain and periodically update a list of certified independent review organizations;

(4) The commissioner shall periodically review the accreditation for all certified independent review organizations;

(5) Whenever the commissioner determines that an independent review organization no longer satisfies the minimum qualifications established under Ins 2703.07(b), the commissioner shall terminate the certification of the independent review organization and remove it from the list of certified independent review organizations that is maintained by the commissioner pursuant to Ins 2703.07(a) (5); and

(6) A certification under this section shall be valid for a period of 2 years.

(b) To be certified under Ins 2703.07(a) to conduct external reviews, an independent review organization shall, in addition to maintaining accreditation by a nationally recognized accrediting entity, meet the following minimum qualifications:

(1) It shall develop and maintain written policies and procedures that govern all aspects of both the standard external review process and the expedited external review process;

(2) It shall establish and maintain a quality assurance program 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 peer reviewers to conduct external reviews on behalf of the independent review organization with suitable matching of reviewers to specific cases;

c. Ensures the confidentiality of medical and treatment records;

d. Ensures that any potential conflict of interest is promptly detected and either remedied by the substitution of an alternative clinical peer reviewer or reported to the commissioner for instruction as to how to proceed; and

e. Ensures that any person employed by or under contract with the independent review organization adheres to the requirements of this section;

(3) It shall assign clinical peer reviewers to conduct external reviews who:

a. Are physicians or other appropriate health care providers;

b. Are experts in the treatment of the covered person's medical condition that is the subject of the external review;

c. Are knowledgeable about the recommended health care service or treatment through actual clinical experience;

d. Hold a non-restricted license in a state of the United States and, for physicians, a current certification by a specialty board recognized by the American Board of Medical Specialties in the area or areas appropriate to the subject of the external review;

e. 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 regulatory body that raise a substantial question as to the clinical peer reviewer's physical, mental or professional competence or moral character; and

f. Have agreed to promptly disclose any potential conflict of interest.

(4) The independent review organization shall be free of any conflict of interest and shall not own or control or in any way be owned or controlled by a health carrier, a national, state, or local trade association of health carriers, or a national, state, or local trade association of health care providers; and

(5) To qualify to conduct an external review of a specific case, neither the independent review organization selected to conduct the external review nor any clinical peer reviewer shall have a material professional, familial or financial interest in or relationship with or to any of the following:

a. The health carrier that is the subject of the external review;

b. Any officer, director, or management employee of the health carrier that is the subject of the external review;

c. 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;

d. The facility or institution at which the recommended health care service or treatment would be provided;

e. 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; or

f. The covered person or the covered person's authorized representative.

(c) In determining whether an independent review organization or a clinical peer reviewer of the independent review organization has a material professional, familial or financial conflict of interest for purposes of Ins 2703.07(b) (5), the commissioner shall consider whether the relationship has the potential to directly or indirectly cause the interests of the IRO or its agents or employees acting on its behalf, to interfere with the independent external reviews of health carrier determinations conducted by the independent review organization.

(d) For the purpose of allowing in-state health care providers to act as clinical peer reviewers in the conduct of external reviews, an affiliation with a hospital, an institution, an academic medical center, or a health carrier provider network shall not be deemed by itself to constitute a conflict of interest which is sufficient to preclude that provider from acting as a clinical peer reviewer, so long as the affiliation is disclosed to the covered person or the covered person's authorized representative and the covered person does not object.

(e) The following organizations shall not be eligible for certification to conduct external reviews:

(1) Professional or trade associations of health care providers;

(2) Subsidiaries or affiliates of such provider associations;

(3) Health carrier or health plan associations; and

(4) Subsidiaries or affiliates of health plan or health carrier associations.

(f) The external review organization's charges for services provided shall be competitive and reasonable, consistent with Ins 2703.09(a).

N.H. Admin. Code § Ins 2703.07

#7539, eff 8-1-01; ss by #8862, eff 5-1-07

Amended by Volume XXXV Number 36, Filed September 10, 2015, Proposed by #10918, Effective 9/1/2015, Expires9/1/2025.