18 Del. Admin. Code § 1301-9.0

Current through Register Vol. 28, No. 5, November 1, 2024

Section 1301-9.0 - Approval of Independent Utilization Review Organizations

9.1 The Department shall approve IUROs eligible to be assigned to conduct IHCAP reviews as provided in 18 Del.C. § 6417 (a).

9.2 An IURO seeking approval to conduct IHCAP reviews shall submit an application to the Department that includes the information required by 18 Del.C. §§ 6417 (c)(1), 6417(c)(2), 6417(c)(4), and a copy of its certification by URAC or other nationally recognized certification organization.

9.3 The Department shall maintain a current list of approved IUROs.

9.4 In connection with each external review, neither the expert reviewer, nor the independent review organization, shall have any material professional, familial or financial conflict of interest with any of the following:

9.4.1 The plan;

9.4.2 Any officer, director or management of the plan;

9.4.3 The physician, the physician's medical group or the independent practice association proposing the service or treatment;

9.4.4 The institution at which the service or treatment would be provided;

9.4.5 The development or manufacture of the principal drug, device, procedure or other therapy proposed for the covered person whose treatment is under review;

9.4.6 The covered person; or

9.4.7 Any national, state or local trade association of health benefit plans or health-care providers.

18 Del. Admin. Code § 1301-9.0

19 DE Reg. 923 (4/1/2016)
21 DE Reg. 580 (1/1/2018) (Final)