31.10.19.03

.03 Conflicts of Interest Standards for Independent Review Organizations and Medical Experts.

A. An independent review organization or medical expert may not be an affiliate of a trade association of:

(1) Health benefit plans; or

(2) Health care providers.

B. The independent review organization shall provide to the Commissioner the following:

(1) The name and biographical information for each director, officer, and management employee of the independent review organization, and a description of any relationship, either direct or indirect, the named individual has that represents ownership of or income from any of the following entities:

(a) A health maintenance organization;

(b) An insurer;

(c) A private review agent;

(d) A nonprofit health corporation;

(e) A carrier dental plan organization;

(f) A health care provider or health care provider group; or

(g) Any group acting on behalf of any of the entities described by §B(1)(a)—(f) of this regulation;

(2) If the independent review organization is a publicly held organization, the names of all stockholders and owners of more than 5 percent of any stock or options of the independent review organization;

(3) The names of all holders of bonds or notes in excess of $100,000;

(4) A list of any currently outstanding loans or contracts to provide services between the independent review organization and any entity listed in §B(1) of this regulation;

(5) The names of all affiliates of the independent review organization and the nature and extent of any ownership or control, including:

(a) The affiliate's type of business; and

(b) A chart or list clearly identifying the relationships between the independent review organization and any affiliates; and

(6) A list of any currently outstanding loans or contracts to provide services between the independent review organization and any affiliates.

C. The medical expert, or independent review organization on behalf of the expert reviewer, shall provide to the Commissioner the following:

(1) The name and biographical information for the medical expert or expert reviewer, and a description of any relationship, either direct or indirect, the medical expert or expert reviewer has which represents ownership of or income from any of the following entities:

(a) A health maintenance organization;

(b) An insurer;

(c) A private review agent;

(d) A nonprofit health organization;

(e) A carrier dental plan organization;

(f) A health care provider or health care provider group; or

(g) Any group activity on behalf of any of the entities described by §C(1)(a)—(f) of this regulation;

(2) A list of any currently outstanding loans or contracts to provide services between the medical expert or expert reviewer and any entity listed in §B(1) of this regulation;

(3) The names of all affiliates of the medical expert or expert reviewer and the nature and extent of any ownership or control, including:

(a) The affiliate's type of business; and

(b) A chart or list clearly identifying the relationships between the medical expert or expert reviewer and any of the affiliates; and

(4) A list of any currently outstanding loans or contracts to provide services between the medical expert or expert reviewer and any affiliates.

D. An expert reviewer assigned by an independent review organization or a medical expert selected by the Commissioner may not have a material professional, familial, or financial conflict of interest with any of the following:

(1) The carrier that is the subject of the complaint;

(2) Any officer, director, or management employee of the carrier that is the subject of the complaint;

(3) The member that is subject to the adverse decision;

(4) The health care provider, the health care provider's medical group, or the independent practice association that rendered or is proposing to render the health care service that is under review;

(5) The health care facility at which the health care service was provided or will be provided; or

(6) The developer or manufacturer of the principal drug, device, procedure, or other therapy that is being proposed for the member.

E. The independent review organization or medical expert shall report any material changes in the information submitted to the Commissioner not later than the 30th day before the date on which the change takes effect.