In order to qualify for certification, an IRO shall:
- (1) Submit an application for certification to the commissioner as described in RCW 48.43.537.
- (2) Hold a current accreditation from a nationally recognized private accrediting organization acceptable to the federal Department of Health and Human Services or Department of Labor for the federal external review process.
- (3) Demonstrate expertise and a history of reviewing health care in terms of medical necessity, appropriateness, and application of other health plan coverage and contract provisions.
- (4) Demonstrate the ability to handle a full range of review cases, including contract provisions, occurring in Washington state. Certified IROs may contract with more specialized review organizations; however, the certified IRO shall ensure that each review conducted meets all the requirements of this chapter.
- (5) Demonstrate capability to review administrative and contractual coverage issues, as well as medical necessity and effectiveness, and the appropriateness of experimental and investigational treatments.
- (6) Comply with all conflict of interest provisions in WAC 284-43A-050.
- (7) Maintain and assign qualified expert reviewers in compliance with WAC 284-43A-060.
- (8) Conduct reviews, reach determinations and document determinations consistent with WAC 284-43A-040 through 284-43A-090.
- (9) Maintain administrative processes and capabilities in compliance with WAC 284-43A-040.
[Statutory Authority: RCW 48.02.060, 48.43.535, and 48.43.537. WSR 16-23-168 (Matter No. R 2016-17), § 284-43A-020, filed 11/23/16, effective 1/1/17.]