Utah Admin. Code R590-261-7 - Independent Review Organizations

(1) The commissioner shall compile and maintain a list of approved independent review organizations.

(2) To be considered for placement on the list in Subsection (1), an independent review organization shall:

(a) be accredited by a nationally recognized private accrediting entity;

(b) comply with the requirements of this rule; and

(c) establish and maintain written policies and procedures that ensure:

(i) all reviews are conducted within a specified time frame;

(ii) a clinical reviewer is qualified and impartial;

(iii) confidentiality of medical and treatment records and clinical review criteria; and

(iv) any person employed by or under contract with the independent review organization adheres to the requirements of this rule.

(3) An applicant requesting placement on the list in Subsection (1) shall submit to the commissioner:

(a) a completed Independent Review Organization Application form, available on the department's website, https://insurance.utah.gov;

(b) all documentation and information requested on the application, including proof of accreditation by a nationally recognized private accrediting entity; and

(c) an application fee.

(4) An independent review organization shall be removed from the list in Subsection (1) if the commissioner finds that the independent review organization lost its accreditation or no longer satisfies the minimum requirements for approval.

(5)

(a) An independent review organization may not be owned or controlled by, or exercise control over:

(i) a carrier;

(ii) a health benefit plan;

(iii) a health benefit plan's fiduciary;

(iv) a national, state, or local trade association of:

(A) health benefit plans;

(B) carriers; or

(C) health care providers;

(v) an employer; or

(vi) an employee or agent of a person listed in Subsections (5)(a)(i) through (5)(a)(v).

(b) An independent review organization and a clinical reviewer assigned to conduct an independent review may not have a professional, familial, or financial conflict of interest with:

(i) the carrier;

(ii) an officer, director, or management employee of the health plan;

(iii) the health benefit plan;

(iv) the plan administrator, plan fiduciary, or a plan employee;

(v) the claimant;

(vi) the insured's health care provider;

(vii) the health care provider's medical group or independent practice association;

(viii) the health care facility where the service is provided; or

(ix) the developer or manufacturer of the service that is provided.

Notes

Utah Admin. Code R590-261-7

Amended by Utah State Bulletin Number 2023-10, effective 5/9/2023