La. Admin. Code tit. 37 § XIII-6211
Current through Register Vol. 50, No. 11, November 20, 2024
Section XIII-6211 - Assignment of Cases to IRO for External ReviewA. When an external review is requested and deemed eligible for review, the commissioner will randomly assign that case to an approved IRO for an external review.B. IROs will be notified of a case assignment via email, which will also include the external review case number specific to the case. To access the case via the industry access portal, click on the link that will be provided in the notice of assignment email.C. To open and access the case file, click on the "View" button next to the case number. From there, the IRO will have access to the insured's contact information, or the insured's authorized representative's contact information, and supporting documentation for review. The IRO will also enter on this screen its final decision to either uphold or reverse the adverse determination. When the IRO submits its decision in the case, it will receive a confirmation message that the decision was successfully submitted.D. Notification of the case assignment will also be given to the covered person and the health insurance issuer, and will include the name and contact information of the IRO to whom the case has been assigned.E. Reassignment of an external review may occur only when: 1. there exists a conflict of interest pursuant to R.S. 22:2441(D). If a conflict exists, the LDI must be informed of such conflict via the industry access link;2. the IRO is not qualified to perform the type of review requested;3. the IRO loses its accreditation; or4. the IRO fails to meet the minimum requirements as set forth in R.S. 22:2441.F. Should an IRO reassignment be necessary, the commissioner will immediately and randomly reassign another IRO to conduct the review. La. Admin. Code tit. 37, § XIII-6211
Promulgated by the Department of Insurance, Office of the Commissioner, LR 41:2174 (October 2015).AUTHORITY NOTE: Promulgated in accordance with R.S. 22:2452.