Section 22-B6008. INDEPENDENT REVIEW ORGANIZATIONS

 

6008.1Each entity or organization seeking to operate as an IRO shall be certified by the Director.

 

6008.2Each organization or entity seeking certification shall submit to the Director an application for certification as an IRO on a form specified by the Director.

 

6008.3The IRO shall, in addition to the submissions required under § 108(e) of the Act, D.C. Code, 2001 Ed. §44-301.08(e), and § 6008.2, attach a review plan which includes the following:

 

(a)Types of reviews performed, including methodology for reviewing:

 

(1)Pre-authorization decisions;

 

(2)Pre-admission decisions;

 

(3)Admission decisions;

 

(4)Emergency admission decision; and

 

(5)Second surgical opinion decisions;

 

(b)Copies of specific criteria and standards to be used in conducting reviews of proposed or delivered health care services including:

 

(1)List of interpretive guidelines used by IRO that identifies the titles, author, publisher and edition of the guideline;

 

(2)Copies of interpretive guidelines for which there are no applicable copyright laws; and

 

(3)A written protocol describing each type of review performed;

 

(c)Forms used and completed during any review;

 

(d)Specified time frames in which the organization completes its review, to include at a minimum:

 

(1)For matters involving emergency or urgent medical conditions, the IRO shall make a determination within seventy-two (72) hours from the time the Director assigns the external review; and

 

(2)For non-emergency matters, the IRO shall make a determination within thirty (30) business days from the time the Director assigns the external review;

 

(e)Qualifications and background of the personnel making the final determination; and

 

(f)Policies and procedures to ensure the confidentiality and non-disclosure of documents and other records used in conducting reviews.

 

6008.4In determining the capability of an IRO, the Director shall determine whether the entity or organization:

 

(a)Maintains a policy or procedure to conduct a review in strict confidence;

 

(b)Uses qualified, independent professional and medical reviewers in all reviews;

 

(c)Demonstrates the ability to render decisions in an equitable and timely manner consistent with the Act and these rules; and

 

(d)Is not a subsidiary of or in any way owned or controlled by a health benefits plan, insurer, or trade organization of health care providers.

 

6008.5The Director shall certify the entity or organization as an IRO when the requirements of § 108(e) of the Act, D.C. Code, 2001 Ed. §44-301.08(e), and these rules have been satisfied. IROs shall be re-certified every two (2) years.

 

6008.6All applications and submissions made by an IRO in accordance with § 108(e) of the Act, D.C. Code, 2001 Ed. §44-301.08(e) shall be treated as public documents.

 

6008.7The IRO shall, as a part of the contract process, submit to the Director and shall maintain with the Director a current list fully identifying all insurers, health care facilities and other health care providers with whom the IRO maintains any health related business arrangement. The list shall include a description of the nature of such arrangements and shall be updated annually.

 

6008.8The terms and conditions of a contract entered into by the Director pursuant to § 108(j) of the Act, D.C. Code, 2001 Ed. §44-301.08(j), shall provide for an assessment of costs for the external review process, not including the costs of representation of a member, to be paid by the insurer.

 

source

Final Rulemaking published at 47 DCR 229 (January 14, 2000).