Section 3 AAC 28.974 - Minimum qualifications for independent review organizations(a) An independent review organization is eligible to conduct external reviews under 3 AAC 28.950 - 3 AAC 28.982, if the independent review organization has and maintains written policies and procedures that govern all aspects of the standard external review process and the expedited external review process and include, at a minimum, the following:(1) a quality assurance mechanism that ensures(A) that external reviews are conducted not later than the specified time frames and that required notices are provided in a timely manner;(B) the selection of qualified and impartial clinical reviewers to conduct external reviews on behalf of the independent review organization, and the suitable matching of reviewers to specific cases;(C) that the independent review organization employs or contracts with an adequate number of clinical reviewers to meet the objectives under (B) of this paragraph; (D) the confidentiality of medical and treatment records and clinical review criteria;(E) the establishment and maintenance of written procedures to ensure that the independent review organization is unbiased, in addition to other procedures required under this section; and(F) that a person employed by or under contract with the independent review organization adheres to the requirements under 3 AAC 28.950 - 3 A.AC 28.982;(2) a toll-free telephone service to receive information related to external reviews 24 hours a day, seven days a week, that is capable of accepting, recording, or providing appropriate instruction to incoming telephone callers outside normal working hours; and(3) an agreement and a system to maintain requited records and to provide the director with access to those records; the agreement must include a provision that the independent review organization shall reply in writing not later than five working days after reviewing a records inquiry from the director.(b) A clinical reviewer assigned by an independent review organization to conduct an external review must be a physician or other appropriate health care professional who meets the following minimum qualifications;(1) is an expert in the treatment of the covered person's medical condition that is the subject of the external review;(2) is knowledgeable about the recommended or requested health care service or treatment through recent or current actual clinical experience treating patients with the same or similar medical condition as the covered person;(3) holds a nonrestricted license in a state of the United States and, for physicians, a current certification by a nationally recognized medical specialty board in the area or areas appropriate to the subject of the external review; and(4) has no history or disciplinary actions or sanctions, including loss of staff privileges or participation restrictions, that have been taken or are pending by a 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) 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 health care insurer, a national, state, or local trade association of health care insurers, or a national, state, or local trade association of health care providers.(d) An independent review organization selected to conduct an external review, or a clinical reviewer assigned by the independent organization to conduct an external review, may not have a material professional, familial, or financial conflict of interest with (1) the health care insurer that is the subject of the external review:(2) the covered person whose health care service or treatment is the subject of the external review or the covered person's authorized representative;(3) an officer, director, or management employee of the health care insurer that is the subject of the external review;(4) the health care professional or the health care professional's medical group or independent practice association recommending the health care service or treatment that is the subject of the external review;(5) the facility at which the recommended health care service or treatment would be provided; or(6) the developer or manufacturer of the principal drug, device, procedure, or other therapy being recommended for the covered person whose health care service or 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 materia! professional, familial, or financial conflict of interest under (d) of this section, the director will take into consideration situations where the independent review organization to be assigned to conduct an external review of a specified case 61* 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 (d) of this section, but the characteristics of that relationship or connection are such that they do not constitute a material professional, familial, or financial conflict of interest that would prohibit selection of the independent review organization or the clinical reviewer to conduct the external review.(f) An independent review organization is presumed to be in compliance with the requirements of this section if the organization is accredited by a nationally recognized private accrediting entity that has independent review accreditation standards that the director has determined are equivalent to, or exceed, the minimum qualifications of this section.(g) The director will initially and periodically review the standards of each nationally recognized private accrediting entity that accredits independent review organizations to determine whether the accrediting entity's standards are, and continue to be, equivalent to, or exceed, the minimum qualifications established under this section. The director may make the determination based on a National Association of Insurance Commissioners review of the standards.(h) Upon request, a nationally recognized private accrediting entity shall provide its current independent review organization accreditation standards to the director or to the National Association of Insurance Commissioners for the director to determine if the accrediting entity's standards arc equivalent to, or exceed, the minimum qualifications established under this section, The director will not consider the accreditation of an independent review organization if the accrediting entity has not had its standards reviewed by the National Association of Insurance Commissioners.Eff. 3/15/2018,Register 225, April 2018Authority:AS 21.06.090
AS 21.07.005