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.

  • Independent Review Organization: Internal Review 5.0 / 11.28.2017

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

    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.

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  • Independent Review Organization: Internal Review 5.0 / 11.28.2017

    IR-INT 4 - Reviewer Qualifications

    Under this standard, the IRO must establish qualifications for its reviewers. At a minimum, those requirements must include the following:Current, non-restricted license or certificate as required under U.S. law for clinical practice;At least five years FTE experience with direct clinical care;Must be a clinical peer (i.e., "a physician or other health professional who holds an unrestricted licens...

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  • Independent Review Organization: Internal Review 5.0 / 11.28.2017

    IR-INT 3 - Credential Status Changes

    This standard requires that the IRO have and implement policies and procedures that both require the IRO's staff members to notify the IRO in the event there is an adverse change in the status of the staffer's license or certification (including board certification) andprovide a procedure to implement a corrective action plan in the event of such an adverse change.In other words, if a member of th...

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