Independent Review Organization: Internal Review 5.0

IR-INT 5 - Internal Review: Additional Reviewer Qualifications for Appeals

Submited by: Tom Goddard

The Basics

IROs must have more rigorous qualifications for reviewers handling appeals. In addition to the requirements outlined in the previous standards, reviewers handling appeals must be board certified, if an MD, DO, or DPM.

Management Tips

MDs' certification must be from a board approved by the ABMS. DOs' certification must be from a board approved by the AOA. DPMs' certification must be either from the ABPS or the ABPOPPM.

Be sure your policies describe in detail your primary source verification process for board certification. Note that URAC does not recognize "board eligible" as a status for purposes of this standard.

Although this is not mentioned explicitly in this standard, your policies must be clear on the fact that the IRO, and not the client, select the reviewer.

Accreditation Tips

Desktop Review

For this standard, submit both the applicable policy describing the assignment of reviewers to cases and a job description or template agreement describing the minimum qualifications for reviewers.

Validation Review

Document review

As a part of the case file review described in previous standards, the URAC reviewer will assess whether each case's reviewer meets the IRO's qualification requirements.


Compliance with this standard will be assessed in interviews of both staff members and the selected peer reviewers.

  • IRO Core 3.0 / 12.28.2017

    IRO CORE 38 - Consumer Safety Mechanism

    One of the most important of the URAC standards is this one, which requires that the organization have processes to respond quickly to urgent situations that threaten consumers' well-being.Even though the standard speaks of "a mechanism", the reality is that it requires a system of mechanisms dealing with the full array of urgent situations that are likely to confront the applicant. You can see th...

  • IRO Core 3.0 / 12.28.2017

    IRO CORE 33 - Financial Incentive Policy

    This standard says, essentially, that if the organization has a system by which people are provided financial incentives that are based directly on consumer utilization of healthcare services, there must be mechanisms in place to make sure that these incentives don't end up compromising consumer care. This policy includes capitation of providers. Not all URAC reviewers over the years have interp...

  • IRO Core 3.0 / 12.28.2017

    IRO CORE 32 - Senior Clinical Staff Responsibilities

    The senior clinician whose qualifications are set forth in Core 31 must, according to this standard, provide guidance and be responsible for all of the clinical aspects of the organization's program being accredited. In addition, the senior clinician must have periodic consultation with individuals in the field or licensed to deliver healthcare services without supervision, i.e. practitioners. F...