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
(9) Maintain administrative processes and capabilities in compliance with WAC 284-43A-040
[Statutory Authority: RCW 48.02.060
, and 48.43.537
. WSR 16-23-168 (Matter No. R 2016-17), § 284-43A-020, filed 11/23/16, effective 1/1/17.]