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Washington Administrative Code (Last Updated: November 23, 2016) |
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Title 284. Insurance Commissioner, Office of |
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Chapter 284-43A. Independent review organizations (IROs). |
Section 284-43A-040. Administrative processes and capabilities of IROs.
Latest version.
- (1) An IRO shall maintain written policies and procedures covering all aspects of review.(2) An IRO shall ensure the confidentiality of medical records and other personal health information received for use in independent reviews, in accordance with applicable federal and state laws.(3) An IRO shall have a quality assurance program that ensures the timeliness, quality of review, and communication of determinations to enrollees and carriers. The quality assurance program must ensure the qualifications, impartiality, and freedom from conflict of interest of the organization, its staff, and expert reviewers.(a) The quality assurance program must include a written plan addressing scope and objectives, program organization, monitoring and oversight mechanisms, and evaluation and organizational improvement of IRO activities.(b) Quality of reviews includes use of appropriate methods to match the case, confidentiality, and systematic evaluation of complaints for patterns or trends. Complaints must be recorded, including the nature of the complaint and the resolution. The commissioner may examine the complaint records.(c) Organizational improvement efforts must include the implementation of action plans to improve or correct identified problems, and communication of the results of action plans to staff and reviewers.(4) An IRO shall maintain case logs and case files with full documentation of referrals, reviewers, questions posed, information considered (including sources of the information and citations of studies or criteria), determinations and their rationale, communication with parties in the dispute including notices given, and key dates in the process, for at least six years following the review.(5) An IRO shall maintain a training program for staff and expert reviewers, addressing at least:(a) Confidentiality;(b) Neutrality and conflict of interest;(c) Appropriate conduct of reviews;(d) Documentation of evidence for determination; and(e) In the case of contract specialists, principles of health contract law and any provisions of Washington state law determined to be essential.(6) An IRO shall maintain business hours, methods of contact (including by telephone), procedures for after-hours requests, and other relevant procedures to ensure timely availability to conduct expedited as well as regular reviews.(7) An IRO shall not disclose reviewers' identities. The commissioner will not require reviewers' identities as part of the certification application process, but may examine identified information about reviewers as part of enforcement activities.(8) An IRO shall promptly report any attempt at interference by any party, including a state agency, to the commissioner.(9) An IRO shall have a medical director who holds a current unrestricted license as a medical doctor or osteopathic physician and has had experience in direct patient care. The medical director shall provide guidance for clinical aspects of the independent review process and oversee the IRO's quality assurance and credentialing programs.