Pennsylvania Statutes Title 40 P.S. Insurance § 991.2164j. Minimum qualifications for independent review organizations

(1) A quality assurance mechanism in place that ensures:

(2) A toll-free telephone service to receive information 24 hours per day, 7 days per week, related to external reviews, that is capable of accepting, recording or providing appropriate instruction to incoming telephone callers during other-than-normal business hours.

(3) An agreement to maintain and provide to the department the information described in section 2164.12.  3

(1) Has expertise in the treatment of the covered person's or enrollee's medical condition that is the subject of the external review.

(2) Is knowledgeable about the recommended health care service through recent or current actual clinical experience treating patients with the same or similar medical condition of the covered person or enrollee.

(3) Holds a nonrestricted license in a state or commonwealth of the United States and, for a physician, a current certification from a recognized American medical specialty board in the area or areas of medicine appropriate to the subject of the external review.

(4) Has no history of 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.

(1) In addition to the requirements under this section, to be approved under section 2164.9 to conduct an external review of a specified case, neither the IRO selected to conduct the external review nor a clinical reviewer assigned by the IRO to conduct the external review may have a material professional, familial or financial conflict of interest with any of the following:

(2) In determining whether an IRO or clinical reviewer of the IRO has a material professional, familial or financial conflict of interest for purposes of paragraph (1), the department shall take into consideration situations where an apparent conflict of interest under paragraph (1) is not material.

(1) An IRO that is accredited by a nationally recognized private accrediting entity that possesses independent review accreditation standards that the department has determined are equivalent to or exceed the minimum qualifications of this section shall be presumed to be in compliance with this section to be eligible for approval under section 2164.9.

(2) The department shall initially and periodically review the IRO accreditation standards of a nationally recognized private accrediting entity to determine whether the entity's standards are, and continue to be, equivalent to or exceeding the minimum qualifications established under this section. The department may accept a review conducted by the NAIC for the purposes of the determination under this paragraph.

(3) Upon request, a nationally recognized private accrediting entity shall make its current IRO accreditation standards available to the department or the NAIC in order for the department to determine if the entity's standards exceed or are equivalent to the minimum qualifications established under this section. The department may exclude a private accrediting entity that is not reviewed by the NAIC.