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.

Interviews

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

  • Core 4.0 / 06.20.2018

    C-RM 1-2: Policy Addressing Reporting of Violations

    This standard requires your organization’s compliance policies to:Protect individuals reporting violations of ethical, regulatory, or legal requirements;Address the consequences of failing to report violations; andProtect the confidentiality of anyone reporting violations.

    READ FULL POST
  • Core 4.0 / 06.18.2018

    C-RM 1-1: Regulatory Compliance and Internal Controls

    This standard, which bears a strong resemblance to Core 4 in the previous versions of Core, describes the fundamental aspects of an effective compliance program:Tracking applicable laws and regulations. This is an ongoing process of tracking existing laws and regulations and keeping up with changes in those laws and regulations. So, you need to identify -- in a clear and specific policy and proced...

    READ FULL POST
  • Core 4.0 / 06.18.2018

    C-CPE 2-3: Monitoring and Oversight of Ethical Healthcare Practices

    Once an organization has defined ethical practices, as required by the previous standard, it must implement mechanisms to monitor for violations of its ethical standards and address those violations. Such mechanisms must spell out how it:Identifies appropriate authorities to remediate particular situations involving ethical transgressions;Will take action in the event of ethical issues; andWill re...

    READ FULL POST
Top