TITLE 50: INSURANCE
CHAPTER I: DEPARTMENT OF INSURANCE
SUBCHAPTER ww: HEALTH CARE SERVICE PLANS
PART 4530 HEALTH CARRIER EXTERNAL REVIEW
SECTION 4530.APPENDIX C INDEPENDENT REVIEW ORGANIZATIONS APPLICATION FOR REGISTRATION
Section 4530.APPENDIX C Independent Review Organizations – Application for Registration
INDEPENDENT REVIEW ORGANIZATION
6. For Each Independent Review Program supply the following information:
a. The name, address, telephone number and hours of operation for the independent review program.
b. The organization and governing structure of the independent review program.
c. The number of reviews in Illinois for which an independent review is conducted by each independent review program for the current year.
d. Number of reviews in Illinois for which an independent review was conducted for the previous calendar year for each independent review program.
e. A copy of your most recent certificate from American Accreditation Healthcare Commission (URAC) Standards for Independent Review Organizations, if applicable.
f. Written policies and procedures for protection of confidential information according to applicable State and federal laws for each independent review program.
g. Biographical information for organization officers and directors. Biographical affidavits shall be stamped "confidential" by the independent review organization (form required by Appendix E).
h. A list of all contracted reviewers, the physician's license number of each reviewer and his or her contact information and area of clinical expertise.
i. All information required in 7 below.
7. Minimum Qualifications for Independent Review Organizations:
a. To be approved to conduct external reviews, an independent review organization shall have and maintain written policies and procedures that govern all aspects of both the standard external review process and the expedited external review process set forth in the Act that include, at a minimum:
i. A quality assurance mechanism that ensures that:
A. External reviews are conducted within the specified timeframes and required notices are provided in a timely manner;
B. Selection of qualified and impartial clinical reviewers to conduct external reviews on behalf of the IRO and suitable matching of reviewers to specific cases and that the independent review organization employs or contracts with an adequate number of clinical reviewers to meet this objective;
C. For adverse determinations involving experimental or investigational treatments, in assigning clinical reviewers, the independent review organization selects physicians or other health care professionals who, through clinical experience in the past 3 years, are experts in the treatment of the covered person's condition and knowledgeable about the recommended or requested health care service or treatment;
D. The health carrier, the covered person, and the covered person's authorized representative shall not choose or control the choice of the physicians or other health care professionals to be selected to conduct the external review;
E. Confidentiality of medical and treatment records and clinical review criteria;
F. Any person employed by or under contract with the independent review organization adheres to the requirements of the Act;
ii. A toll-free telephone service and email address operating on a 24 hours/day, 7 days/week basis that accepts, receives, and records information related to external reviews and provides appropriate instructions;
iii. Name, phone number and direct email address of contact persons who will be responsible for handling assignments of external reviews; and
iv. An agreement to maintain and provide to the Director the information set out in Section 65 of the Act.
b. All clinical reviewers assigned by an independent review organization to conduct external reviews shall be physicians or other appropriate health care providers who meet the following minimum qualifications:
i. Be an expert in the treatment of the covered person's medical condition that is the subject of the external review;
ii. Be knowledgeable about the recommended health care service or treatment through recent or current actual clinical experience treating patients with the same or similar medical condition as the covered person;
iii. Hold a non-restricted 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
iv. 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 unit, or regulatory body that raise a substantial question as to the clinical reviewer's physical, mental, or professional competence or moral character.
c. In addition to the requirements set forth in subsection (a), an independent review organization may 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.
d. Conflicts of interest are prohibited. In addition to the requirements set forth in 7a, 7b and 7c of this Section, to be approved pursuant to the Act to conduct an external review of a specified case, neither the independent review organization selected to conduct the external review nor any clinical reviewer assigned by the IRO to conduct the external review may have a material professional, familial or financial conflict of interest with any of the following:
i. The health carrier that is the subject of the external review;
ii. The covered person whose treatment is the subject of the external review or the covered person's authorized representative;
iii. Any officer, director or management employee of the health carrier that is the subject of the external review;
iv. The health care provider, 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;
v. The facility at which the recommended health care service or treatment would be provided; or
vi. 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.
e. An independent review organization shall be unbiased. An IRO shall establish and maintain written procedures to ensure that it is unbiased in addition to any other procedures required under this Section.
f. Nothing in this Section precludes or shall be interpreted to preclude a health carrier from contracting with approved independent review organizations to conduct external reviews assigned to it from the health carrier.
g. An independent review organization that meets or exceeds the accreditation standards for Independent Review Organizations set forth by the American Accreditation Healthcare Commission (URAC) and otherwise meets the qualifications of this Section shall be presumed to be in compliance with this Section and shall be eligible for approval.
8. Check Enclosed (Please make checks payable to Director of Insurance)
a. Accredited entity fee of $1000 biennially.
b. Unaccredited entity fee of $1500 biennially in the event that the Director determines that there are no acceptable nationally recognized private accrediting entities providing independent review organization accreditation.
Please mail completed application to:
Illinois Department of Insurance
Utilization Review Unit
320 West Washington Street
Springfield IL 62767-0001
(Source: Amended at 39 Ill. Reg. 4077, effective September 1, 2015)