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10.09.86.00.htm 10.09.86.00. Title 10 DEPARTMENT OF HEALTH AND MENTAL HYGIENE Subtitle 09 MEDICAL CARE PROGRAMS Chapter 86 Maryland Medicaid Managed Care Program: Independent Review Organization (IRO) Authority: Health-General Article, §2-104(b) 15-103(b) Annotated Code of Maryland
10.09.86.01.htm 10.09.86.01. 01 Scope and Purpose.. This chapter provides for a complaint resolution process for disputes between managed care organizations (MCOs) and providers regarding adverse medical necessity decision made by MCOs. Pursuant to this chapter, providers that receive an adverse medical necessity decision on claims for reimbursement may submit the adverse decision for review by an Independent Review Organization (IRO) designated by the Department.
10.09.86.02.htm 10.09.86.02. 02 Definitions.. A. In this chapter, the following terms have the meanings indicated.. B. Terms Defined.. 1) "Adverse decision" means a review determination by a managed care organization that a health care service for which a provider seeks reimbursement is not medically necessary.2) "Affiliate" means a person who, directly or indirectly, through one or more intermediaries, controls, is controlled by, or is under common control with another person.
10.09.86.03.htm 10.09.86.03. 03 Use of Independent Review Organizations.. A. The Department shall procure the services of an IRO to make determinations of medical necessity on provider complaints regarding adverse decisions.B. An IRO that contracts with the Department shall assure, in accordance with its contract with the Department, the:1) Timeliness and quality of the reviews;. 2) Qualifications and independence of the IRO and expert reviewers; and.
10.09.86.04.htm 10.09.86.04. 04 Conflicts of Interest Standards for Independent Review Organizations and Expert Reviewers.. A. An IRO or expert reviewer may not be an affiliate or have a financial, familial or professional relationship with any facility, provider, or organization that has filed a complaint.B. Upon request by the Department, the IRO shall provide to the Department information demonstrating compliance with the requirement in §A of this regulation.
10.09.86.05.htm 10.09.86.05. 05 Assignment of an Expert Reviewer.. A. The IRO shall ensure that an expert reviewer:. 1) Has appropriate clinical expertise in the treatment of the specific medical condition being reviewed and holds a nonrestricted license as a health care provider in the United States; and2) Has no history of disciplinary investigations, actions, or sanctions, including loss of staff privileges or participation restrictions that have been taken or are pending by any hospital, governmen
10.09.86.06.htm 10.09.86.06. 06 Independent Review.. A. A provider shall exhaust an MCO’s provider appeal process before filing a complaint with the IRO.. B. A provider shall file a complaint with the IRO in the form provided by the IRO not later than 30 calendar days following the date of an MCO’s adverse decision.C. A review of an adverse decision shall be based on the case record.. D. The IRO shall, after reviewing the case record, issue a final decision as to whether the health care services that are the
10.09.86.07.htm 10.09.86.07. 07 Payment of Fees and Sanctions.. A. In the event that a provider’s complaint is unsuccessful, the provider is responsible for paying to the IRO the case review charge established by the Department.B. The case review charge established by the Department shall be based on the contract between the Department and the IRO arrived at through a competitive procurement process.C. An MCO that is determined by the IRO to have improperly denied, either in whole or in part, a pro
10.09.86.08.htm 10.09.86.08. 08 Appeal.. A. As a prerequisite for participating in the IRO complaint adjudication process, a provider waives all other administrative and judicial appeal rights and accepts the IRO’s decision as final and binding.B. An MCO that receives an adverse decision from an independent review organization may file an appeal in accordance with COMAR 10.09.72.06.
10.09.86.9999.tx.htm 10.09.86.9999. Administrative History Effective date: April 28, 2014 (41:8 Md. R. 471).
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