044-63 Wyo. Code R. §§ 63-12 - Minimum Qualifications for Independent Review Organizations
(a) To be approved under Section 11 of this
Rule to conduct external reviews, an independent review organization shall have
and maintain written policies and procedures that govern all aspects of both
the standard external review process and the expedited external review process
set forth in this Rule that include, at a minimum:
(i) A quality assurance mechanism in place
that:
(A) Ensures that external reviews are
conducted within the specified time frames and required notices are provided in
a timely manner;
(B) Ensures the
selection of qualified and impartial clinical reviewers to conduct external
reviews on behalf of the independent review organization and suitable matching
of reviewers to specific cases and that the independent review organization
employs or contracts with an adequate number of clinical reviewers to meet this
objective;
(C) Ensures the
confidentiality of medical and treatment records and clinical review criteria;
and
(D) Ensures that any person
employed by or under contract with the independent review organization adheres
to the requirements of this Rule;
(ii) A toll-free telephone service to receive
information on a 24-hour-day, 7-day-a-week basis related to external reviews
that is capable of accepting, recording or providing appropriate instruction to
incoming telephone callers during other than normal business hours; and
(iii) Agree to maintain and
provide to the commissioner the information set out in Section 14 of this Rule.
(b) All clinical
reviewers assigned by an independent review organization to conduct external
reviews shall be health care professionals or other appropriate health care
providers who meet the following minimum qualifications:
(i) Be an expert in the treatment of the
claimant's medical condition that is the subject of the external
review;
(ii) Be knowledgeable about
the recommended health care service or treatment through recent or current
actual clinical experience treating patients with the same or similar medical
condition of the claimant;
(iii)
Hold a non-restricted license in a state of the United States and, for
physicians, a current certification by a recognized American medical specialty
board in the area or areas appropriate to the subject of the external review;
and
(iv) Have no history of
disciplinary actions or sanctions, including loss of staff privileges or
participation restrictions, that have been taken or are pending by any
hospital, governmental agency or unit, or regulatory body that raise a
substantial question as to the clinical reviewer's physical, mental or
professional competence or moral character.
(c) In addition to the requirements set forth
in paragraph (a) of this section an independent review organization may not own
or control, be a subsidiary of or in any way be owned or controlled by, or
exercise control with a insurance policy, a national, state or local trade
association of insurance policies, or a national, state or local trade
association of health care providers.
(d) In addition to the requirements set forth
in paragraph (a), (b) and (c) of this section, to be approved pursuant to
Section 11 of this Rule to conduct an external review of a specified case,
neither the independent review organization selected to conduct the external
review nor any clinical reviewer assigned by the independent organization to
conduct the external review may have a material professional, familial or
financial conflict of interest with any of the following:
(i) The insurer that is the subject of the
external review;
(ii) The claimant
whose treatment is the subject of the external review or the claimant's
authorized representative;
(iii)
Any officer, director or management employee of the insurer that is the subject
of the external review;
(iv) The
health care provider, the health care provider's medical group or independent
practice association recommending the health care service or treatment that is
the subject of the external review;
(v) The facility at which the recommended
health care service or treatment would be provided; or
(vi) The developer or manufacturer of the
principal drug, device, procedure or other therapy being recommended for the
claimant whose treatment is the subject of the external review.
(e) In determining whether an
independent review organization or a clinical reviewer of the independent
review organization has a material professional, familial or financial conflict
of interest for purposes of paragraph (d) of this section, the commissioner
shall take into consideration situations where the independent review
organization to be assigned to conduct an external review of a specified case
or a clinical reviewer to be assigned by the independent review organization to
conduct an external review of a specified case may have an apparent
professional, familial or financial relationship or connection with a person
described in paragraph (d) of this section, but that the characteristics of
that relationship or connection are such that they are not a material
professional, familial or financial conflict of interest that results in the
disapproval of the independent review organization or the clinical reviewer
from conducting the external review.
(f) An independent review organization that
is accredited by URAC or another nationally recognized private accrediting
entity that has independent review accreditation standards that the
commissioner has determined are equivalent to or exceed the minimum
qualifications of this section shall be presumed in compliance with this
section to be eligible for approval under Section 11 of this Rule.
(g) The commissioner shall initially review
and periodically review the independent review organization accreditation
standards of URAC and other nationally recognized private accrediting entities
to determine whether the entity's standards are, and continue to be, equivalent
to or exceed the minimum qualifications established under this section. The
commissioner may accept a review conducted by the NAIC for the purpose of the
determination under this paragraph.
(h) Upon request, a nationally recognized
private accrediting entity shall make its current independent review
organization accreditation standards available to the commissioner or the NAIC
in order for the commissioner to determine if the entity's standards are
equivalent to or exceed the minimum qualifications established under this
section. The commissioner may exclude any private accrediting entity that is
not reviewed by the NAIC.
(i) An
independent review organization shall be unbiased. An independent review
organization shall establish and maintain written procedures to ensure that it
is unbiased in addition to any other procedures required under this section.
Notes
State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.
No prior version found.