Certification of Independent Review Organizations

Bulletin

99

CERTIFICATION OF

INDEPENDENT REVIEW ORGANIZATIONS

October 7, 1999

This Bulletin is directed to all health maintenance organizations (HMOs) doing business

in Indiana and to all organizations interested in acting as independent review organizations for the

HMO external grievance procedures set forth in IC 27-13-10.1.

IC 27-13-10.1, as added by P.L. 133-1999, requires each HMO doing business in Indiana

to establish and maintain an external grievance procedure for the resolution of grievances

regarding adverse utilization review determinations, adverse determinations of medical necessity

or determinations that a proposed service is experimental or investigational. The Department of

Insurance (Department) is required to establish and maintain a process for annual certification of

independent review organizations and to maintain a list of certified independent review

organizations to be used by HMOs. This Bulletin sets forth the procedure for certification as an

independent review organization (IRO).

Request for Certification as an Independent Review Organization

In order to be considered for certification, organizations must submit a Request for

Certification to the Department, in duplicate. The Request must comply with all instructions

contained in this Bulletin; incomplete requests will not be considered. A Request shall include the

following information:

♦

Identifiable and specific responses to each criteria set forth in this Bulletin and IC 27-13­

10.1;

♦

A statement certifying that all information included in the Request for Certification is

accurate to the best of the Applicant’s knowledge and belief and signed by the

Applicant’s chief executive officer or an individual authorized to act in such capacity for

the Applicant;

♦

Consecutive page numbering and identification of sections

criteria set forth in this Bulletin and IC 27-13­

10.1;

♦

A statement certifying that all information included in the Request for Certification is

accurate to the best of the Applicant’s knowledge and belief and signed by the

Applicant’s chief executive officer or an individual authorized to act in such capacity for

the Applicant;

♦

Consecutive page numbering and identification of sections.

Section 1 – Technical/Procedure

This section shall describe the organization's approach and plans for accomplishing the

external grievance review process described in IC 27-13-10.1. The organization should describe

the effort and skills necessary to complete the process. This section shall contain at least the

following information:

1) A summary of the organization’s case review process, which demonstrates an understanding

of the law governing the external review process.

2) A description of how the work will be accomplished within each step of the case review

process. Simple statements that a task will be completed or a reiteration of the criteria are not

acceptable. The description should explain the process to be employed in reviewing an

HMO’s determination and include a flow chart depicting the process by which external

review will proceed from the receipt of the request for review to the final decision. The

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explanation should address the criteria used in the decision-making process and the systems

and methods used to process case reviews, including the following:

a) Process for providing a decision in the statutorily mandated amount of time.

b) Process for selecting and assigning reviewers to cases including the recruitment and

contracting, credentialing, and assignment of appropriate specialists to cases.

c) Process for ensuring independence. Include any contract provisions with reviewers that

require the contracted reviewer to review the case for potential conflicts of interest before

accepting the assignment

ed amount of time.

b) Process for selecting and assigning reviewers to cases including the recruitment and

contracting, credentialing, and assignment of appropriate specialists to cases.

c) Process for ensuring independence. Include any contract provisions with reviewers that

require the contracted reviewer to review the case for potential conflicts of interest before

accepting the assignment.

d) Process for maintaining the confidentiality of medical and treatment records and any

other review materials during communication with parties involved in the review process

and during “in house” communication.

e) Process for communication with parties involved in the review process. Include any

requirements for the process that HMOs must follow when submitting the request for

external review and the case file.

f) Process for requesting and receiving additional information from HMOs or other parties.

Include any requirements that responses be submitted by a particular method (i.e.

overnight mail, facsimile). Include whether the organization will recontact an HMO if

information is not provided in a timely fashion and process for doing so.

g) Process for rendering and communicating decisions.

h) Process for maintaining written records pertaining to each case review and the retention

schedule of those records.

3) A summary of any problems the organization might reasonably expect in the external review

process, and anticipated solutions to those problems.

4) A drafted format for the annual report to the Department required by IC 27-13-10.1-8(c)(3).

5) A description of the statistics maintained by the IRO that will be made available to the

Department on request.

Section 2 – Cost

This section shall contain all information related to fees to be charged by the organization to

the HMO.

1) Fees charged for each review should be reasonable in relation to the work performed

e annual report to the Department required by IC 27-13-10.1-8(c)(3).

5) A description of the statistics maintained by the IRO that will be made available to the

Department on request.

Section 2 – Cost

This section shall contain all information related to fees to be charged by the organization to

the HMO.

1) Fees charged for each review should be reasonable in relation to the work performed. Work

performed should be broken down into the following review types:

a) preliminary review;

b) situations where full review is not necessary owing to reversal by the HMO of its adverse

determination due to new information; and

c) full review.

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2) If the fee structure is other than a flat, per case rate, provide the basis upon which it is

determined and include the anticipated average cost per case.

3) A statement that all fee schedules submitted with the Request for Certification will not be

increased during the one-year certification period.

Section 3 – Organizational Support and Experience

This section shall contain all pertinent information relating to the organization’s personnel

and experience that would substantiate its qualifications and capabilities to perform external

reviews as described in IC 27-13-10.1.

This section shall contain at least the following

information.

1) Certification of incorporation or partnership and location of applicant’s headquarters and

offices in or nearest to Indiana.

2) Any organization requesting certification as an IRO must provide the following information

about the organization and any parent corporation, subsidiary, or affiliate:

a) Name and address of each member of the board of directors;

b) Name and address of any owner, partner or any other person with 10% or more voting

shares;

3) A chart illustrating the relationship among all affiliated entities

Any organization requesting certification as an IRO must provide the following information

about the organization and any parent corporation, subsidiary, or affiliate:

a) Name and address of each member of the board of directors;

b) Name and address of any owner, partner or any other person with 10% or more voting

shares;

3) A chart illustrating the relationship among all affiliated entities.

4) An internal organizational chart that identifies key grievance review staff members and their

responsibilities within the organization. It shall provide an estimate of the number, types, and

functions of the personnel considered necessary to the administration and operation of the

organization in Indiana with a separate job description detailing the roles of key persons. It

shall describe the contractual and financial relationships between the organization and the

clinical personnel who will be responsible for individual case reviews.

5) A list of personnel who may be assigned to individual case reviews. For each reviewer, the

list shall include the name, professional license(s), board certification(s), and any history of

disciplinary actions or sanctions that raise a substantial question as to the reviewer’s physical,

mental or professional competence or moral character, including loss of staff privileges, or

restrictions on participation, taken or pending by any hospital, government or regulatory

body.

6) A list of all managed care organizations, hospitals, health care facilities, and other health care

providers with whom the organization maintains any health related business arrangements.

This list shall include a brief description of the nature of any such arrangement.

7) A description of how the organization will:

a) Provide licensed review personnel who possess the appropriate training and qualifications

in the medical subject area for which they will be conducting the review. Include the

criteria to be used for the selection or rejection of review personnel

arrangements.

This list shall include a brief description of the nature of any such arrangement.

7) A description of how the organization will:

a) Provide licensed review personnel who possess the appropriate training and qualifications

in the medical subject area for which they will be conducting the review. Include the

criteria to be used for the selection or rejection of review personnel.

b) Ensure the availability of appropriate personnel as needed for timely and efficient review.

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c) Ensure the neutrality and objectivity of all personnel conducting external reviews,

including avoidance of conflicts of interest or the appearance of a conflict of interest.

8) A description of the organization’s quality assurance program for case review.

9) Documentation which clearly shows the organization’s experience in performing similar

reviews. Describe the organization’s experience in managed care utilization review, including

an explanation of level(s) and scope of involvement in the utilization review process. The

organization may also provide a list of references including entities for which the applicant

has performed similar review under any state or federal external grievance review law.

10) A statement that the organization agrees to accept all eligible cases referred to it on the

rotating basis required to be used by HMOs.

11) A statement that the Request for Certification designates agreement to comply with IC 27-13-

10.1.

12) A list of all professional designations and/or licenses held by the organization and a brief

explanation of all credentials held by the organization from other states and credentialing

organizations.

13) A description of any disciplinary actions or sanctions taken or ongoing against the

organization in the preceding ten (10) years

cation designates agreement to comply with IC 27-13-

10.1.

12) A list of all professional designations and/or licenses held by the organization and a brief

explanation of all credentials held by the organization from other states and credentialing

organizations.

13) A description of any disciplinary actions or sanctions taken or ongoing against the

organization in the preceding ten (10) years.

Department Review

The Department may:

♦ Approve any number of entities for certification as IROs;

♦ Reject any request for certification or recertification if determined by the Commissioner

to be necessary, appropriate, or in the best interests of HMOs and their enrollees;

♦ Suspend, revoke or otherwise sanction an organization’s IRO certification if the

Commissioner determines that the organization is not in substantial compliance with the

information provided in the organization’s request for certification, any applicable law, or

any regulation or other guidance issued by the Commissioner;

♦ Request that an organization alter its activities to be consistent with any applicable law or

any regulation or other guidance issued by the Commissioner;

♦ Deny or reassign a request for external review if the Commissioner has reason to believe

that such an assignment would result in or create the appearance of a conflict of interest

or if the Commissioner determines that the organization cannot or has not conducted the

review in accordance with the statute.

Timelines

The IRO Certification List will be effective January 1, 2000. In order to be considered

for certification and inclusion on the January 1, 2000 list, Requests for Certification must be

delivered to the Department on or before December 1, 1999. The period of certification will be

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ermines that the organization cannot or has not conducted the

review in accordance with the statute.

Timelines

The IRO Certification List will be effective January 1, 2000. In order to be considered

for certification and inclusion on the January 1, 2000 list, Requests for Certification must be

delivered to the Department on or before December 1, 1999. The period of certification will be

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one (1) year. The IRO Certification List will be published on the Department website:

www.state.in.us/idoi.

There will be a six (6) month update of the IRO Certification List on June 1, 2000. Any

organization that wishes to be considered for certification and inclusion on the June 1, 2000 list

must deliver a Request for Certification to the Department by May 1, 2000. Organizations added

to the June 1, 2000 list must reapply for the 2001 certification period.

Beginning January 1, 2001, IRO certification and/or re-certification will be performed on

an annual basis. Requests for certification or re-certification must be delivered to the Department

on or before December 1 of each year.

Submission of Request for Certification

Requests for Certification and any questions may be submitted by mail or electronically.

Mail:

Deputy Commissioner, Health Issues

Indiana Department of Insurance

311 W. Washington, Suite 300

Indianapolis, IN 46204-2787

Fax:

(317) 232-5251

Electronic:

doi@doi.state.in.us

Requests submitted electronically must be a

Microsoft Word document.

Sally McCarty, Commissioner

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