Medical Necessity in Private Health Plans

Table 8. Qualifications of External Reviewer in State IRO Statutes

Jurisdiction	Reviewer	Entity that Selects Reviewer	Requirement that Reviewer Have Relevant Expertise or Particular Case? (X if yes)	Conflict of Interest Prohibition (X if yes)
Alaska	Certified appeal agency using panels of "two clinical peers." Agency must be certified by a private standard-setting organization approved by Department of Health or a health insurer operating in state.	MCO		X
Arizona	IRO using physicians and other health professionals licensed in Arizona or another state (if board-certified or eligible).	Department of Health	X	X
California	IRO certified by Insurance Commissioner and using health care providers licensed in California and board-certified.	Department of Insurance	X	X
Colorado	IRO certified by Insurance Commissioner and using physicians or other health care professionals.	Department of Insurance	X	X
Connecticut	IRO may include medical peer review organizations, independent utilization review companies, or nationally recognized health experts or institutions approved by the Insurance Commissioner.	Department of Insurance	X	X
Delaware	IRO certified by Secretary of Health or accredited by an independent national accrediting organization and includes licensed and board-certified physicians or other appropriate health care providers.	Department of Health	X	X
District of Columbia	IRO consisting of at least two physicians licensed in D.C., Maryland, or Virginia (exceptions when necessary due to the condition under review) who have meaningful experience in prior utilization review.	Department of Insurance	X (noted "when necessary")	X
Florida	IRO panel consisting of individuals from the Agency for Health Care Administration, the Department of Insurance, a consumer, a physician appointed by the Governor, physicians with relevant expertise to case at issue (rotating pool), and a medical director from an MCO (not a party) and a primary care physician.	Agency for Health Care Administration	X
Georgia	IRO with licensed and board-certified health care providers certified by the Department of Health Planning Division.	Department of Health Planning Division	X	X
Hawaii	Three-member panel appointed by the Insurance Commissioner and composed of a representative from the managed care plan not involved in the complaint, a provider licensed in Hawaii not involved in the complaint, and the Commissioner or Commissioner's designee. The Commissioner may also retain an IRO to assist in the review.	Commissioner of Insurance		X
Illinois	A physician who holds the same class of license as the patient's primary care physician and who is appointed by the patient, the primary care physician, and the MCO.	MCO
Indiana	IRO certified by the Department of Insurance assigns a medical review professional who is licensed and board certified in applicable specialty for the appeal and who has knowledge about the proposed service at issue.	MCO (but must go through the entire list of certified IROs before selecting the same one again)	X	X
Iowa	IROs certified by the Insurance Commissioner may include (but are not limited to) medical peer review organizations and nationally recognized health experts or institution. Individual reviewer must hold applicable health care license and be board-certified.	MCO selects from list of certified IROs	X	X
Kansas	IRO under contract with Commissioner of Insurance. IRO must have experience in administering Kansas health programs or be a nationally accredited external review organization that uses Kansas health care providers to conduct the review (unless no Kansas providers are qualified and credentialed in the specialty at issue in the case)	Commissioner of Insurance	X	X
Kentucky¹	IROs must use a reviewer(s) with the appropriate license, board certification, and clinical experience applicable to the medical condition under review.	Department of Insurance	X	X
Louisiana	IRO must be licensed by the Insurance Commissioner and have qualified and impartial clinical peer reviewers who hold appropriate licenses and board certification in the specialty at issue and have clinical expertise in the relevant medical condition.	MCO	X	X
Maine	IRO must have qualified and impartial reviewers who hold applicable licenses and board certification with respect to the adverse health care treatment under review.	Insurance Bureau	X	X
Maryland	The Commissioner may make a determination on a patient's appeal or designate an IRO to do so. An IRO must have qualified and impartial reviewers who hold applicable licenses and board certification with respect to the adverse health care treatment under review.	Commissioner of Insurance	X	X
Massachusetts	Department of Public Health's Office of Patient Protection contracts with "unrelated and objective" review agencies and refers appeals to them on a random basis. Reviewers are to be actively practicing health care professionals in the same or similar specialty who typically treat the medical condition, perform the procedure or provide the treatment under review.	Department of Public Health, Office of Patient Protection	X	X
Michigan	IROs approved by Commissioner of Insurance. IROs must use reviewers licensed and board-certified in the applicable specialty and who have had an active clinical practice in the last year in which the reviewer "devoted a majority of his or her time in ...the specialty most relevant to the subject of the review."	Commissioner of Insurance	X	X
Minnesota	IRO under contract to Commissioner of Health and using qualified reviewers.	Commissioners of Health, Administration	X	X
Missouri²	IRO under contract to the Department of Insurance.	Director of Insurance
Montana	Party seeking review and the MCO may agree upon a peer to conduct the review (a peer is defined as "a health care provider actively practicing in this state who has substantially the same education and training...who provides substantially the same service...who has the same license or certification...as the provider whose practice...[is] being considered, reviewed, evaluated or judged." If the parties cannot agree on a peer, then the Insurance Department designates an IRO.	Insurance Department	X	X
New Hampshire	Commissioner of Insurance certifies IROs. Reviewers must hold appropriate licenses and board certification in the specialty at issue and have clinical expertise in the relevant medical condition.	Commissioner of Insurance	X	X
New Jersey	IROs conduct an initial review through a registered professional nurse or physician licensed in New Jersey, and, when necessary, refer all cases to a consultant physician in the specialty or area of practice that generally would manage the type of treatment that is the subject of the appeal.	Commissioner of Health	Provides "when necessary" but does not require (and does not define "when necessary" but implies this determination is in the discretion of the IRO).
New Mexico	The Superintendent of Insurance designates a hearing officer (an attorney licensed in New Mexico) and two medical co-hearing officers (at least one of whom practices in a specialty that would typically manage the case that is the subject of the review).	Superintendent of Insurance	X	Requires disclosure of potential conflicts to Superintendent but does not prohibit conflicts
New York	The Superintendent of Insurance and the Commissioner of Health certify IROs and randomly assign appeals to them. IRO reviewers must have the appropriate license, board certification, and clinical experience applicable to the medical condition under review.	Superintendent of Insurance and Commissioner of Health	X	X
North Carolina	Insurance Commissioner assigns IRO on a rotating basis from list of approved organizations. IRO reviewers must have the appropriate license, board certification, and clinical experience applicable to the medical condition under review.	Insurance Commissioner	X	X
Ohio	Insurance Superintendent accredits IROs and maintains a list of approved organizations. Upon a request for external appeal, Superintendent provides two IROs chosen at random from the list, and the MCO chooses one of them. One reviewer conducts the review (unless the MCO or IRO determines that more than one is necessary), and the reviewer(s) must have the appropriate license, board certification, and clinical experience applicable to the medical condition under review.	Insurance Superintendent (MCO chooses among two IROs selected at random)	X	X
Oklahoma	MCO selects IRO from a list of organizations certified by the Department of Health. Reviewers have the appropriate license, board certification, and clinical experience applicable to the medical condition under review.	MCO chooses from Department of Health-certified organizations.	X	X
Oregon	When legislation becomes effective (July 1, 2002), Director of Business and Consumer Affairs Department will contract with IROs qualified under regulations to be developed prior to July 1, 2002.	Director of Business and Consumer Affairs Department	To Be Determined	To Be Determined
Pennsylvania³	Insurance Commissioner assigns IRO on a rotating basis from list of approved organizations. IRO reviewers must have the appropriate license, board certification, and clinical experience applicable to the medical condition under review. Reviewers may include licensed psychologists (although they cannot review denials of inpatient care or prescription drugs). If Insurance Commissioner fails to assign an IRO within 2 business days of the request for review, the MCO may assign an IRO from list of organizations approved by Insurance Department.	Insurance Commissioner (or MCO if Insurance Commissioner fails to assign IRO within 2 business days of request for external review)	X	X
Rhode Island	Insurance Department certifies IROs. Reviewer must be a physician, dentist, or other health care professional of the specialty relevant to the care or service under review.	Designated by Insurance Director	X	X
South Carolina	Insurance Department maintains list of approved IROs and designates IRO upon request for external review. IRO reviewers must have the appropriate license, board certification, and clinical experience (within the past three years) applicable to the medical condition under review.	Insurance Department	X	X
Tennessee	MCO designates IRO, which must be impartial and use reviewers that have the appropriate license and board certification applicable to the medical condition under review.	MCO	X	X
Texas	Department of Insurance assigns IROs randomly from an approved list. Reviewers must be in active practice and have the appropriate license and board certification applicable to the medical condition under review.	Department of Insurance	X	X
Utah	MCO designates IRO, which must be impartial.	MCO
Vermont	Commissioner of Department of Banking, Insurance, Securities, and Health Care Administration (BISHCA) designates IROs. Reviewers must be in active practice and have the appropriate license and board certification applicable to the medical condition under review. An Independent Panel of Mental Health Care Providers reviews decisions involving mental health services, including drug and alcohol treatment.	Commissioner of BISHCA	X	X
Virginia	IROs contract with the Bureau of Insurance. Reviewers must have the appropriate license and board certification applicable to the medical condition under review.	Bureau of Insurance	X	X
Washington	Department of Health certifies IROs and maintains registry for assignment. Reviewers must have five years of clinical experience and have the appropriate license and board certification applicable to the medical condition. Under review.	Department of Health	X	X
West Virginia⁴	The Department of Insurance certifies IROs, which must use at least one physician or other health care provider knowledgeable about the health care service under review.	Department of Insurance	X	X

¹ A patient cannot obtain an external review if the subject of the patient's adverse determination has previously gone through the external review process and the independent review entity found in favor of the insurer and no new clinical evidence is available. Ken. Rev. Stat. ß 304.17A-623(6).

2 Missouri has three levels of review for adverse medical determinations. The first level is internal to the health plan, and the second level is external but arranged by the health plan (involving other enrollees, representatives of the plan not involved in the case, and clinicians not involved in the case). The third level is independent review and is the level addressed in this analysis. See Rev. Stat. Mo. ß 376.1385 (2000).

3 Pennsylvania allows an MCO and provider to agree to an alternate dispute resolution system in a written contract if the Insurance Department approves of the alternate system. 40 Pa. Stat. ß 991.2162.

4 West Virginia allows MCOs an exemption from the IRO statute if the MCO has an external review plan approved by the Department of Insurance. W. Va. Code ß 33-25C-6.

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