Section 246-305-020. General requirements for certification.

In order to qualify for certification, an IRO shall:

(1) Submit an application for certification to the department as described in WAC 246-305-080.

(2) Hold a current accreditation from a nationally recognized private accrediting organization acceptable to the federal Department of Health and Human Services or Department of Labor for the federal external review process.

(3) Demonstrate expertise and a history of reviewing health care in terms of medical necessity, appropriateness, and the application of other health plan coverage provisions.

(4) Demonstrate the ability to handle a full range of review cases occurring in Washington state. Certified IROs may contract with more specialized review organizations; however, the certified IRO shall ensure that each review conducted meets all the requirements of this chapter.

(5) Demonstrate capability to review administrative and contractual coverage issues, as well as medical necessity and effectiveness, and the appropriateness of experimental and investigational treatments.

(6) Comply with all conflict of interest provisions in WAC 246-305-030.

(7) Maintain and assign qualified expert reviewers in compliance with WAC 246-305-040.

(8) Conduct reviews, reach determinations and document determinations consistent with WAC 246-305-050 and 246-305-060.

(9) Maintain administrative processes and capabilities in compliance with WAC 246-305-070.

[Statutory Authority: RCW 43.70.235 and 48.43.535. WSR 11-23-124, § 246-305-020, filed 11/21/11, effective 11/26/11; WSR 01-08-023, § 246-305-020, filed 3/28/01, effective 4/28/01.]

RCW 43.70.235 and 48.43.535. WSR 11-23-124, § 246-305-020, filed 11/21/11, effective 11/26/11; WSR 01-08-023, § 246-305-020, filed 3/28/01, effective 4/28/01.

Rules

246-305-080,246-305-030,246-305-040,246-305-050,246-305-060,246-305-070,