Sec. 10.67.13.06. Independent Review

A. A provider shall exhaust an MCO’s provider appeal process before filing a complaint with the IRO.

B. A provider shall file a complaint with the IRO in the form provided by the IRO not later than 30 calendar days following the date of an MCO’s adverse decision.

C. A review of an adverse decision shall be based on the case record.

D. The IRO shall, after reviewing the case record, issue a final decision as to whether the health care services that are the subject of the complaint were medically necessary.

E. The final decision shall state in writing the factual bases for the decision of the expert reviewer and reference the criteria and standards on which the expert reviewer's decision was based.

F. Final decisions shall be rendered within 45 days of submission of the case record, unless the time period is extended by the Department.