Independent Review Organization: Internal Review 5.0
IR-INT 1 - Reviewer Credentialing Program
This standard requires that the IRO implement a credentialing program for its reviewers. That program must include:
- selection criteria for its reviewers; and
- verification of credentials of its reviewers.
Reviewer verification must occur before the IRO assigns any cases to a reviewer and again no later than the date the reviewers' credentials are scheduled to expire.
In addition, the IRO must implement a policy and procedure that prevents the IRO's staff from assigning cases to a reviewer whose credentials are inactive or not yet re-verified.
The description of the reviewer credentialing process that is required by this standard may be a program description, P&Ps, or other official document. The key is that it must be a formal document, approved under the processes described in IRO Core 3.
Naturally, the document describing the program must describe, in enough detail for a staff person to use the document to guide his/her activities, the entire credentialing process. Be sure to include a description of how the IRO periodically verifies sanctions or disciplinary actions.
In addition, reviewers should be required by the IRO to notify the organization in the event there is a change in status of licensure or certification.
The organization should be able to produce a roster of available reviewers, including information about credentialing, suspension, and verification of credentials.
The IRO may establish its own selection criteria. URAC will audit whether the IRO's credentialing process accurately tracks the IRO's criteria.
The organization must submit official documents that describe in detail all the processes referenced by this standard.
The URAC reviewer will interview members of the staff who implement the policies that are the subject of this standard, including staff members who select reviewers and those who verify credentials. In addition, the URAC reviewer will interview two peer reviewers, to be selected by the IRO.
The URAC reviewer will need to see the most current policies or credentialing plan to check on any changes since the submission of the document(s) for desktop review. In addition, the reviewer will select at least 30 case files, randomly chosen from a list of case files. Each file will need to be accompanied by the file corresponding to the reviewer(s) that handled each such case.