Independent Review Organization Accreditation Standards Summary

Accreditation Overview.

Independent review is a process, independent of all affected parties, to determine if a health care service is medically necessary, medically appropriate, experimental or investigational. Independent review typically (but not always) occurs after all appeals mechanisms available within the health benefits plan have been exhausted. Independent review is sometimes referred to as external review.

Independent review is largely driven by state laws and URAC has attempted to design and implement an accreditation program benchmarking the activities of independent review organizations to be consistent with existing laws and to assist states in their efforts to oversee the independent review process.URAC does not include the federal Medicare programs within the scope of the IRO accreditation.

Please note: In addition to the specific standards described below, organizations seeking Independent Review Organization Accreditation must also comply with the Core Standards.

Scope of Services.

Upon receipt of a case, the organization conducts a review of the case to determine if a conflict of interest exists, whether the case relates to a clinical or administrative issue, whether the case refers to medical necessity or experimental/investigational treatment, whether the issue may be resolved through the independent review process and whether the case requires a standard or expedited review. If an organizational conflict of interest exists, the organization returns the case to the referring entity unless, upon full disclosure, it obtains written consent to conduct independent review.

Independent Review Staff.

For each case, the organization verifies that the reviewers do not have a material professional, familial or financial conflict of interest regarding any of the entities involved in the case; do not accept compensation for independent review activities based on the outcome of the case; or do not have involvement with the case prior to its referral to independent review.

The organization establishes and implements selection criteria for reviewers and implements a program to verify the qualifications of the reviewers at least every three years, including the reviewers’ professional credentials. The program also addresses the reviewers’ potential conflicts of interest.

The organization establishes and implements criteria for the number and qualifications of reviewers for each case. The criteria specify that, at a minimum, there is a reviewer who is a clinical peer of the attending provider, who has a scope of licensure and professional experience that encompasses the service or treatment under review, has current experience in managing consumers with the condition under review, has the ability to evaluate alternatives and has the expertise to address the disputed issues.

Independent Review Process.

For each case, the organization maintains a file housing all relevant information. Included in the file are the following: documentation related to the case, copies of relevant documents from the health benefits plan, copies of prior determination letters, for expedited reviews, after hours contact information for the referring entity, documentation of all communications between the entities involved including a copy of the final determination letter, etc. The organization maintains a log of all independent review case files that includes relevant information such as the date the case was received, a description of the issue, the organization’s determination, etc. For each case, the organization selects the reviewers and provides them with a file of the necessary information.

When processing a case regarding medical necessity/appropriateness, the organization and its reviewers must consider information pertinent to the case. This includes the consumer’s medical records, the attending provider’s recommendation, information accumulated regarding the case, etc. When processing a case regarding and experimental or investigational treatment, the organization and its reviewers consider all information pertinent to the case and existing medical research and peer-reviewed literature regarding the treatment with respect to effectiveness and efficacy. When processing a case regarding administrative or legal issues, the organization and its reviewers consider all information necessary to render a decision.

The organization implements mechanisms to request and accept additional information that may assist in rendering a determination. The organization provides any such information received to the health benefits plan and provides the plan an opportunity to reverse its decision.

In cases where more than one reviewer is used, the organization provides an opportunity for the reviewers to discuss the case and accepts the majority decision.

The organization notifies the referring entity within two business days of rendering the determination. Such notice includes the issue referred to independent review, a description of the qualifications of the reviewer and a clinical rationale for the determination. Standard reviews must be completed within a median of 5 business days and in no case longer than 20 business days. Expedited reviews must be available in cases for which the time frame for a standard review would compromise patient welfare and safety. Expedited reviews must be completed as soon as possible and in no case longer than 72 hours from request. The organization notifies the referring entity of the determination immediately upon completion.

The organization provides reasonable telephone access for consumers and attending providers.

Confidentiality.

The organization implements mechanisms to ensure that individually identifiable information obtained during the independent review process is kept confidential in accordance with applicable laws, used solely for the purposes of independent review and quality management and shared only with those individuals that have authority to receive and who need such information.

CLICK HERE for a list of standards you must comply with in order to obtain accreditation.

Created by Matrix Group International, Inc