Sec. 10.67.13.03. Use of Independent Review Organizations

A. The Department shall procure the services of an IRO to make determinations of medical necessity on provider complaints regarding adverse decisions.

B. An IRO that contracts with the Department shall assure, in accordance with its contract with the Department, the:

(1) Timeliness and quality of the reviews;

(2) Qualifications and independence of the IRO and expert reviewers; and

(3) Confidentiality of medical records and review materials, consistent with federal and State laws.

C. An IRO designated by the Department shall have the authority to conduct the following functions:

(1) Obtaining all case information relative to the complaint from the MCO pursuant to time frames established by the Department;

(2) Assigning an expert reviewer for review of an adverse decision;

(3) Performing conflicts checks relative to the independent review organization and the expert reviewer assigned to review the adverse decision;

(4) Communicating procedural rules, as approved by the Department, and other information regarding appeals to the parties;

(5) Rendering a timely final decision in accordance with Regulation .06F of this chapter.