Section 4530.50 Independent Review Organization Obligations

Section 4530.50  Independent Review Organization

Obligations

a)         An

independent review organization may not conduct external independent reviews of

adverse determinations for persons subject to Section 15 of the Act unless the

independent review organization has first registered with the Director. An

application for registration shall be in the format set forth in Appendix C.

b)         An

independent review organization must secure and maintain a current certificate

of accreditation by the American Accreditation Healthcare Commission (URAC)

under applicable standards for Independent Review Organizations.

c)         Each

independent review organization shall provide a written notice as set forth in

Appendix A and Appendix B, explaining its decision to uphold or reverse adverse

or final adverse determinations to the health carrier, the covered person, and,

if applicable, the covered person's authorized representative.

d)         Each

independent review organization shall maintain written records in the

aggregate, by state, and by health carrier on all requests for external review

for which it conducted an external review during a calendar year and submit,

electronically, a report in the format specified by the Director by March 1 of

each year. The independent review organization shall retain the written records

required under the Act for at least three years.