{"formats":[{"name":"JSON","format":"json","url":"\/downloads\/2025\/code-json\/38.2-3565.json"},{"name":"Plain Text","format":"text","url":"\/downloads\/2025\/code-text\/38.2-3565.txt"},{"name":"XML","format":"xml","url":"\/downloads\/2025\/code-xml\/38.2-3565.xml"},{"name":"HTML","format":"html","url":"\/downloads\/2025\/code-html\/38.2-3565.html"}],"law_id":63044,"edition_id":1,"section_id":63044,"structure_id":14588,"section_number":"38.2-3565","catch_line":"Minimum qualifications for independent review organizations","history":"2011, c. 788.","full_text":"A\n\nAn independent review organization shall have and maintain written policies and procedures that govern all aspects of both the standard external review process and the expedited external review process and that include, at a minimum:1\n\nA quality assurance mechanism in place that: ensures that external reviews are conducted within the specified time frames and required notices are provided in a timely manner, ensures the selection of qualified and impartial clinical reviewers to conduct external reviews on behalf of the independent review organization and suitable matching of reviewers to specific cases and that the independent review organization employs or contracts with an adequate number of clinical reviewers to meet this objective, ensures the confidentiality of medical and treatment records and clinical review criteria, and ensures that any person employed by or under contract with the independent review organization adheres to the requirements of this chapter;2\n\nA toll-free telephone service to receive information on a 24-hour-a-day, seven-day-a-week basis that is capable of accepting, recording, or providing appropriate instruction to incoming telephone callers; and3\n\nProvisions for maintaining records and providing reports to the Commission in accordance with the requirements set out in § 38.2-3568.B\n\nAll clinical reviewers assigned by an independent review organization to conduct external reviews shall be physicians or other appropriate health care providers who shall meet the following minimum qualifications:1\n\nBe an expert in the treatment of the covered person’s medical condition that is the subject of the external review;2\n\nBe knowledgeable about the recommended health care service or treatment through recent or current actual clinical experience treating patients with the same or similar medical condition of the covered person;3\n\nHold a nonrestricted license in their health care field in a state and, for physicians, a current certification by a recognized American medical specialty board in the area or areas appropriate to the subject of the external review; and4\n\nHave no history of disciplinary actions or sanctions, including loss of staff privileges or participation restrictions, that have been taken or are pending by any hospital, governmental agency or unit, or regulatory body that raise a substantial question as to the clinical reviewer’s physical, mental, or professional competence or moral character.C\n\nAn independent review organization may not own or control, be a subsidiary of, or in any way be owned or controlled by, or exercise control with, a health benefit plan, a national, state, or local trade association of health benefit plans, or a national, state, or local trade association of health care providers.D\n\nNeither the assigned independent review organization nor any clinical reviewer assigned by the independent organization may have a material professional, familial, or financial conflict of interest with any of the following that is the subject of the external review:1\n\nThe health carrier;2\n\nThe covered person or his authorized representative;3\n\nAny officer, director, or management employee of the health carrier;4\n\nThe health care provider, the health care provider’s medical group, or the independent practice association recommending the health care service or treatment;5\n\nThe facility at which the recommended health care service or treatment would be provided; or6\n\nThe developer or manufacturer of the principal drug, device, procedure, or other therapy being recommended.E\n\nAn independent review organization shall be accredited by a nationally recognized private accrediting entity that has standards that the Commission has determined are equivalent to or exceed the minimum qualifications of this section. The following shall apply with regard to accrediting entities:1\n\nUpon request, a nationally recognized private accrediting entity shall make its current accreditation standards available to the Commission or the NAIC. The Commission shall initially and periodically review the accreditation standards of the nationally recognized private accrediting entity to determine whether the entity’s standards are, and continue to be, equivalent to or exceed the minimum qualifications established under this section;2\n\nThe Commission may accept a review conducted by the NAIC for the purpose of this determination. The Commission may exclude any private accrediting entity that is not reviewed by the NAIC; and3\n\nThe Commission may approve independent review organizations that are not accredited by a nationally recognized private accrediting entity only if there are no acceptable nationally recognized private accrediting entities providing independent review organization accreditation.F\n\nAn independent review organization shall be unbiased. An independent review organization shall establish and maintain written procedures to ensure that it is unbiased.","order_by":null,"text":{"0":{"id":229919,"text":"An independent review organization shall have and maintain written policies and procedures that govern all aspects of both the standard external review process and the expedited external review process and that include, at a minimum:","type":"section","prefixes":["A"],"prefix":"A","entire_prefix":"A","prefix_anchor":"A","level":1,"next_prefix":"A1"},"1":{"id":229920,"text":"A quality assurance mechanism in place that: ensures that external reviews are conducted within the specified time frames and required notices are provided in a timely manner, ensures the selection of qualified and impartial clinical reviewers to conduct external reviews on behalf of the independent review organization and suitable matching of reviewers to specific cases and that the independent review organization employs or contracts with an adequate number of clinical reviewers to meet this objective, ensures the confidentiality of medical and treatment records and clinical review criteria, and ensures that any person employed by or under contract with the independent review organization adheres to the requirements of this chapter;","type":"section","prefixes":["A","1"],"prefix":"1","entire_prefix":"A1","prefix_anchor":"A1","level":2,"prior_prefix":"A","next_prefix":"A2"},"2":{"id":229921,"text":"A toll-free telephone service to receive information on a 24-hour-a-day, seven-day-a-week basis that is capable of accepting, recording, or providing appropriate instruction to incoming telephone callers; and","type":"section","prefixes":["A","2"],"prefix":"2","entire_prefix":"A2","prefix_anchor":"A2","level":2,"prior_prefix":"A1","next_prefix":"A3"},"3":{"id":229922,"text":"Provisions for maintaining records and providing reports to the Commission in accordance with the requirements set out in § 38.2-3568.","type":"section","prefixes":["A","3"],"prefix":"3","entire_prefix":"A3","prefix_anchor":"A3","level":2,"prior_prefix":"A2","next_prefix":"B"},"4":{"id":229923,"text":"All clinical reviewers assigned by an independent review organization to conduct external reviews shall be physicians or other appropriate health care providers who shall meet the following minimum qualifications:","type":"section","prefixes":["B"],"prefix":"B","entire_prefix":"B","prefix_anchor":"B","level":1,"prior_prefix":"A3","next_prefix":"B1"},"5":{"id":229924,"text":"Be an expert in the treatment of the covered person’s medical condition that is the subject of the external review;","type":"section","prefixes":["B","1"],"prefix":"1","entire_prefix":"B1","prefix_anchor":"B1","level":2,"prior_prefix":"B","next_prefix":"B2"},"6":{"id":229925,"text":"Be knowledgeable about the recommended health care service or treatment through recent or current actual clinical experience treating patients with the same or similar medical condition of the covered person;","type":"section","prefixes":["B","2"],"prefix":"2","entire_prefix":"B2","prefix_anchor":"B2","level":2,"prior_prefix":"B1","next_prefix":"B3"},"7":{"id":229926,"text":"Hold a nonrestricted license in their health care field in a state and, for physicians, a current certification by a recognized American medical specialty board in the area or areas appropriate to the subject of the external review; and","type":"section","prefixes":["B","3"],"prefix":"3","entire_prefix":"B3","prefix_anchor":"B3","level":2,"prior_prefix":"B2","next_prefix":"B4"},"8":{"id":229927,"text":"Have no history of disciplinary actions or sanctions, including loss of staff privileges or participation restrictions, that have been taken or are pending by any hospital, governmental agency or unit, or regulatory body that raise a substantial question as to the clinical reviewer’s physical, mental, or professional competence or moral character.","type":"section","prefixes":["B","4"],"prefix":"4","entire_prefix":"B4","prefix_anchor":"B4","level":2,"prior_prefix":"B3","next_prefix":"C"},"9":{"id":229928,"text":"An independent review organization may not own or control, be a subsidiary of, or in any way be owned or controlled by, or exercise control with, a health benefit plan, a national, state, or local trade association of health benefit plans, or a national, state, or local trade association of health care providers.","type":"section","prefixes":["C"],"prefix":"C","entire_prefix":"C","prefix_anchor":"C","level":1,"prior_prefix":"B4","next_prefix":"D"},"10":{"id":229929,"text":"Neither the assigned independent review organization nor any clinical reviewer assigned by the independent organization may have a material professional, familial, or financial conflict of interest with any of the following that is the subject of the external review:","type":"section","prefixes":["D"],"prefix":"D","entire_prefix":"D","prefix_anchor":"D","level":1,"prior_prefix":"C","next_prefix":"D1"},"11":{"id":229930,"text":"The health carrier;","type":"section","prefixes":["D","1"],"prefix":"1","entire_prefix":"D1","prefix_anchor":"D1","level":2,"prior_prefix":"D","next_prefix":"D2"},"12":{"id":229931,"text":"The covered person or his authorized representative;","type":"section","prefixes":["D","2"],"prefix":"2","entire_prefix":"D2","prefix_anchor":"D2","level":2,"prior_prefix":"D1","next_prefix":"D3"},"13":{"id":229932,"text":"Any officer, director, or management employee of the health carrier;","type":"section","prefixes":["D","3"],"prefix":"3","entire_prefix":"D3","prefix_anchor":"D3","level":2,"prior_prefix":"D2","next_prefix":"D4"},"14":{"id":229933,"text":"The health care provider, the health care provider’s medical group, or the independent practice association recommending the health care service or treatment;","type":"section","prefixes":["D","4"],"prefix":"4","entire_prefix":"D4","prefix_anchor":"D4","level":2,"prior_prefix":"D3","next_prefix":"D5"},"15":{"id":229934,"text":"The facility at which the recommended health care service or treatment would be provided; or","type":"section","prefixes":["D","5"],"prefix":"5","entire_prefix":"D5","prefix_anchor":"D5","level":2,"prior_prefix":"D4","next_prefix":"D6"},"16":{"id":229935,"text":"The developer or manufacturer of the principal drug, device, procedure, or other therapy being recommended.","type":"section","prefixes":["D","6"],"prefix":"6","entire_prefix":"D6","prefix_anchor":"D6","level":2,"prior_prefix":"D5","next_prefix":"E"},"17":{"id":229936,"text":"An independent review organization shall be accredited by a nationally recognized private accrediting entity that has standards that the Commission has determined are equivalent to or exceed the minimum qualifications of this section. The following shall apply with regard to accrediting entities:","type":"section","prefixes":["E"],"prefix":"E","entire_prefix":"E","prefix_anchor":"E","level":1,"prior_prefix":"D6","next_prefix":"E1"},"18":{"id":229937,"text":"Upon request, a nationally recognized private accrediting entity shall make its current accreditation standards available to the Commission or the NAIC. The Commission shall initially and periodically review the accreditation standards of the nationally recognized private accrediting entity to determine whether the entity’s standards are, and continue to be, equivalent to or exceed the minimum qualifications established under this section;","type":"section","prefixes":["E","1"],"prefix":"1","entire_prefix":"E1","prefix_anchor":"E1","level":2,"prior_prefix":"E","next_prefix":"E2"},"19":{"id":229938,"text":"The Commission may accept a review conducted by the NAIC for the purpose of this determination. The Commission may exclude any private accrediting entity that is not reviewed by the NAIC; and","type":"section","prefixes":["E","2"],"prefix":"2","entire_prefix":"E2","prefix_anchor":"E2","level":2,"prior_prefix":"E1","next_prefix":"E3"},"20":{"id":229939,"text":"The Commission may approve independent review organizations that are not accredited by a nationally recognized private accrediting entity only if there are no acceptable nationally recognized private accrediting entities providing independent review organization accreditation.","type":"section","prefixes":["E","3"],"prefix":"3","entire_prefix":"E3","prefix_anchor":"E3","level":2,"prior_prefix":"E2","next_prefix":"F"},"21":{"id":229940,"text":"An independent review organization shall be unbiased. An independent review organization shall establish and maintain written procedures to ensure that it is unbiased.","type":"section","prefixes":["F"],"prefix":"F","entire_prefix":"F","prefix_anchor":"F","level":1,"prior_prefix":"E3"}},"ancestry":[{"id":14588,"edition_id":1,"name":"Health Carrier Internal Appeal Process and External Review","identifier":"35.1","label":"chapter","depth":2,"order_by":1,"parent_id":12698,"metadata":{},"date_created":"2026-06-26 03:48:47","date_modified":"2026-06-26 03:48:47","permalink":{"id":215937,"object_type":"structure","relational_id":14588,"identifier":"35.1","token":"38.2\/35.1","url":"\/38.2\/35.1\/","edition_id":1,"permalink":0,"preferred":1}},{"id":12698,"edition_id":1,"name":"Insurance","identifier":"38.2","label":"title","depth":1,"order_by":1,"parent_id":null,"metadata":{},"date_created":"2026-06-26 03:43:49","date_modified":"2026-06-26 03:43:49","permalink":{"id":210661,"object_type":"structure","relational_id":12698,"identifier":"38.2","token":"38.2","url":"\/38.2\/","edition_id":1,"permalink":0,"preferred":1}}],"structure_contents":[{"id":58140,"structure_id":14588,"section_number":"38.2-3556","catch_line":"Definitions","url":"\/38.2-3556\/","token":"38.2\/35.1\/38.2-3556","metadata":false},{"id":56086,"structure_id":14588,"section_number":"38.2-3557","catch_line":"Scope of chapter","url":"\/38.2-3557\/","token":"38.2\/35.1\/38.2-3557","metadata":false},{"id":56843,"structure_id":14588,"section_number":"38.2-3558","catch_line":"Health carrier's internal appeal process","url":"\/38.2-3558\/","token":"38.2\/35.1\/38.2-3558","metadata":false},{"id":77920,"structure_id":14588,"section_number":"38.2-3559","catch_line":"Notice of right to external review","url":"\/38.2-3559\/","token":"38.2\/35.1\/38.2-3559","metadata":false},{"id":65207,"structure_id":14588,"section_number":"38.2-3560","catch_line":"Exhaustion of internal appeal process","url":"\/38.2-3560\/","token":"38.2\/35.1\/38.2-3560","metadata":false},{"id":66856,"structure_id":14588,"section_number":"38.2-3561","catch_line":"Standard external review","url":"\/38.2-3561\/","token":"38.2\/35.1\/38.2-3561","metadata":false},{"id":83961,"structure_id":14588,"section_number":"38.2-3562","catch_line":"Expedited external review","url":"\/38.2-3562\/","token":"38.2\/35.1\/38.2-3562","metadata":false},{"id":63745,"structure_id":14588,"section_number":"38.2-3563","catch_line":"External review of experimental or investigational treatment adverse determinations","url":"\/38.2-3563\/","token":"38.2\/35.1\/38.2-3563","metadata":false},{"id":78633,"structure_id":14588,"section_number":"38.2-3564","catch_line":"Binding nature of external review decision","url":"\/38.2-3564\/","token":"38.2\/35.1\/38.2-3564","metadata":false},{"id":63044,"structure_id":14588,"section_number":"38.2-3565","catch_line":"Minimum qualifications for independent review organizations","url":"\/38.2-3565\/","token":"38.2\/35.1\/38.2-3565","metadata":false},{"id":59040,"structure_id":14588,"section_number":"38.2-3566","catch_line":"Approval of independent review organizations","url":"\/38.2-3566\/","token":"38.2\/35.1\/38.2-3566","metadata":false},{"id":79665,"structure_id":14588,"section_number":"38.2-3567","catch_line":"Independent review organizations to be held harmless","url":"\/38.2-3567\/","token":"38.2\/35.1\/38.2-3567","metadata":false},{"id":81396,"structure_id":14588,"section_number":"38.2-3568","catch_line":"External review reporting requirements","url":"\/38.2-3568\/","token":"38.2\/35.1\/38.2-3568","metadata":false},{"id":75481,"structure_id":14588,"section_number":"38.2-3569","catch_line":"Funding of external review","url":"\/38.2-3569\/","token":"38.2\/35.1\/38.2-3569","metadata":false},{"id":83489,"structure_id":14588,"section_number":"38.2-3570","catch_line":"Disclosure requirements","url":"\/38.2-3570\/","token":"38.2\/35.1\/38.2-3570","metadata":false},{"id":56157,"structure_id":14588,"section_number":"38.2-3571","catch_line":"Regulations","url":"\/38.2-3571\/","token":"38.2\/35.1\/38.2-3571","metadata":false}],"previous_section":{"id":78633,"structure_id":14588,"section_number":"38.2-3564","catch_line":"Binding nature of external review decision","url":"\/38.2-3564\/","token":"38.2\/35.1\/38.2-3564","metadata":false},"next_section":{"id":59040,"structure_id":14588,"section_number":"38.2-3566","catch_line":"Approval of independent review organizations","url":"\/38.2-3566\/","token":"38.2\/35.1\/38.2-3566","metadata":false},"metadata":false,"official_url":"https:\/\/law.lis.virginia.gov\/vacode\/38.2-3565\/","history_text":"

This law was first created in 2011. The record of its establishment is cataloged in chapter 788<\/a> of that year\u2019s edition of \u201cActs of Assembly,\u201d the annual state publication listing all changes made to the Code of Virginia in that year.<\/p>","references":[{"id":63745,"section_number":"38.2-3563","catch_line":"External review of experimental or investigational treatment adverse determinations","order_by":null,"url":"\/38.2-3563\/"}],"refers_to":false,"permalink":{"id":215975,"object_type":"law","relational_id":63044,"identifier":"38.2-3565","token":"38.2\/35.1\/38.2-3565","url":"\/38.2-3565\/","edition_id":1,"permalink":0,"preferred":1},"url":"\/38.2-3565\/","token":"38.2\/35.1\/38.2-3565","dublin_core":{"Title":"Minimum qualifications for independent review organizations","Type":"Text","Format":"text\/html","Identifier":"\u00a7 38.2-3565","Relation":"Code of Virginia"},"html":"\n\t\t\t\t\t\t

A.<\/span> An independent review organization<\/span> shall have and maintain written policies and procedures that govern all aspects of both the standard external review process and the expedited external review process and that include, at a minimum: <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

1.<\/span> A quality assurance mechanism in place that: ensures that external reviews are conducted within the specified time frames and required notices are provided in a timely manner, ensures the selection of qualified and impartial clinical reviewers to conduct external reviews on behalf of the independent review organization<\/span> and suitable matching of reviewers to specific cases and that the independent review organization<\/span> employs or contracts<\/span> with an adequate number of clinical reviewers to meet this objective, ensures the confidentiality of medical and treatment records and clinical review criteria<\/span>, and ensures that any person<\/span> employed by or under contract<\/span> with the independent review organization<\/span> adheres to the requirements of this chapter; <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

2.<\/span> A toll-free telephone service to receive information on a 24-hour-a-day, seven-day-a-week basis that is capable of accepting, recording, or providing appropriate instruction to incoming telephone callers; and <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

3.<\/span> Provisions for maintaining records and providing reports to the Commission<\/span> in accordance with the requirements set out in § 38.2-3568<\/a>. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

B.<\/span> All clinical reviewers assigned by an independent review organization<\/span> to conduct external reviews shall be physicians or other appropriate health care providers<\/span> who shall meet the following minimum qualifications: <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

1.<\/span> Be an expert in the treatment of the covered person<\/span>’s medical condition that is the subject of the external review; <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

2.<\/span> Be knowledgeable about the recommended health care service or treatment through recent or current actual clinical experience treating patients with the same or similar medical condition of the covered person<\/span>; <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

3.<\/span> Hold a nonrestricted license in their health care field in a state<\/span> and, for physicians, a current certification<\/span> by a recognized American medical specialty board in the area or areas appropriate to the subject of the external review; and <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

4.<\/span> Have no history of disciplinary actions or sanctions<\/span>, including loss of staff privileges<\/span> or participation restrictions, that have been taken or are pending by any hospital, governmental agency or unit, or regulatory body that raise a substantial question as to the clinical reviewer’s physical, mental, or professional competence or moral character. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

C.<\/span> An independent review organization<\/span> may not own or control, be a subsidiary of, or in any way be owned or controlled by, or exercise control with, a health benefit plan<\/span>, a national, state<\/span>, or local trade association of health benefit plans<\/span>, or a national, state<\/span>, or local trade association of health care providers<\/span>. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

D.<\/span> Neither the assigned independent review organization<\/span> nor any clinical reviewer assigned by the independent organization may have a material<\/span> professional, familial, or financial conflict of interest<\/span> with any of the following that is the subject of the external review: <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

1.<\/span> The health carrier<\/span>; <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

2.<\/span> The covered person<\/span> or his authorized representative<\/span>; <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

3.<\/span> Any officer, director, or management employee of the health carrier<\/span>; <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

4.<\/span> The health care provider<\/span>, the health care provider<\/span>’s medical group, or the independent practice association recommending the health care service or treatment; <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

5.<\/span> The facility<\/span> at which the recommended health care service or treatment would be provided; or <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

6.<\/span> The developer or manufacturer of the principal drug, device, procedure, or other therapy being recommended. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

E.<\/span> An independent review organization<\/span> shall be accredited by a nationally recognized private accrediting entity that has standards that the Commission<\/span> has determined are equivalent to or exceed the minimum qualifications of this section. The following shall apply with regard to accrediting entities: <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

1.<\/span> Upon request, a nationally recognized private accrediting entity shall make its current accreditation standards available to the Commission<\/span> or the NAIC<\/span>. The Commission<\/span> shall initially and periodically review the accreditation standards of the nationally recognized private accrediting entity to determine whether the entity’s standards are, and continue to be, equivalent to or exceed the minimum qualifications established under this section; <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

2.<\/span> The Commission<\/span> may accept a review conducted by the NAIC<\/span> for the purpose of this determination. The Commission<\/span> may exclude any private accrediting entity that is not reviewed by the NAIC<\/span>; and <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

3.<\/span> The Commission<\/span> may approve independent review organizations<\/span> that are not accredited by a nationally recognized private accrediting entity only if there are no acceptable nationally recognized private accrediting entities providing independent review organization<\/span> accreditation. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

F.<\/span> An independent review organization<\/span> shall be unbiased. An independent review organization<\/span> shall establish and maintain written procedures to ensure that it is unbiased. <\/i><\/a><\/p><\/section>","plain_text":" CODE OF VIRGINIA\n\nMINIMUM QUALIFICATIONS FOR INDEPENDENT REVIEW ORGANIZATIONS (\u00a7 38.2-3565)\n\nA. An independent review organization shall have and maintain written policies\nand procedures that govern all aspects of both the standard external review\nprocess and the expedited external review process and that include, at a\nminimum:\n\n 1. A quality assurance mechanism in place that: ensures that external reviews\n are conducted within the specified time frames and required notices are\n provided in a timely manner, ensures the selection of qualified and impartial\n clinical reviewers to conduct external reviews on behalf of the independent\n review organization and suitable matching of reviewers to specific cases and\n that the independent review organization employs or contracts with an adequate\n number of clinical reviewers to meet this objective, ensures the\n confidentiality of medical and treatment records and clinical review criteria,\n and ensures that any person employed by or under contract with the independent\n review organization adheres to the requirements of this chapter;\n\n 2. A toll-free telephone service to receive information on a 24-hour-a-day,\n seven-day-a-week basis that is capable of accepting, recording, or providing\n appropriate instruction to incoming telephone callers; and\n\n 3. Provisions for maintaining records and providing reports to the Commission\n in accordance with the requirements set out in § 38.2-3568.\n\nB. All clinical reviewers assigned by an independent review organization to\nconduct external reviews shall be physicians or other appropriate health care\nproviders who shall meet the following minimum qualifications:\n\n 1. Be an expert in the treatment of the covered person’s medical\n condition that is the subject of the external review;\n\n 2. Be knowledgeable about the recommended health care service or treatment\n through recent or current actual clinical experience treating patients with\n the same or similar medical condition of the covered person;\n\n 3. Hold a nonrestricted license in their health care field in a state and, for\n physicians, a current certification by a recognized American medical specialty\n board in the area or areas appropriate to the subject of the external review;\n and\n\n 4. Have no history of disciplinary actions or sanctions, including loss of\n staff privileges or participation restrictions, that have been taken or are\n pending by any hospital, governmental agency or unit, or regulatory body that\n raise a substantial question as to the clinical reviewer’s physical,\n mental, or professional competence or moral character.\n\nC. An independent review organization may not own or control, be a subsidiary\nof, or in any way be owned or controlled by, or exercise control with, a health\nbenefit plan, a national, state, or local trade association of health benefit\nplans, or a national, state, or local trade association of health care\nproviders.\n\nD. Neither the assigned independent review organization nor any clinical\nreviewer assigned by the independent organization may have a material\nprofessional, familial, or financial conflict of interest with any of the\nfollowing that is the subject of the external review:\n\n 1. The health carrier;\n\n 2. The covered person or his authorized representative;\n\n 3. Any officer, director, or management employee of the health carrier;\n\n 4. The health care provider, the health care provider’s medical group,\n or the independent practice association recommending the health care service\n or treatment;\n\n 5. The facility at which the recommended health care service or treatment\n would be provided; or\n\n 6. The developer or manufacturer of the principal drug, device, procedure, or\n other therapy being recommended.\n\nE. An independent review organization shall be accredited by a nationally\nrecognized private accrediting entity that has standards that the Commission has\ndetermined are equivalent to or exceed the minimum qualifications of this\nsection. The following shall apply with regard to accrediting entities:\n\n 1. Upon request, a nationally recognized private accrediting entity shall make\n its current accreditation standards available to the Commission or the NAIC.\n The Commission shall initially and periodically review the accreditation\n standards of the nationally recognized private accrediting entity to determine\n whether the entity’s standards are, and continue to be, equivalent to or\n exceed the minimum qualifications established under this section;\n\n 2. The Commission may accept a review conducted by the NAIC for the purpose of\n this determination. The Commission may exclude any private accrediting entity\n that is not reviewed by the NAIC; and\n\n 3. The Commission may approve independent review organizations that are not\n accredited by a nationally recognized private accrediting entity only if there\n are no acceptable nationally recognized private accrediting entities providing\n independent review organization accreditation.\n\nF. An independent review organization shall be unbiased. An independent review\norganization shall establish and maintain written procedures to ensure that it\nis unbiased.\n\nHISTORY: 2011, c. 788.","edition":{"id":1,"name":"2025","slug":"2025","date_created":"2026-06-21 22:39:22","date_modified":"2026-06-21 22:39:22","current":1,"order_by":1,"last_import":null}}