Assignment of an IRO Clause Samples
The Assignment of an IRO clause establishes the process by which an Independent Review Organization (IRO) is designated to review or audit certain activities, typically in the context of compliance or dispute resolution. This clause outlines who has the authority to select the IRO, the criteria the IRO must meet, and the scope of the IRO's responsibilities, such as reviewing billing practices or compliance with regulations. Its core practical function is to ensure that an impartial third party is appointed to provide objective oversight, thereby enhancing transparency and trust between the parties involved.
Assignment of an IRO. If the Member’s request is eligible for external review, The Plan will within 1 business day assign the request for external review on a random basis or using another method of assignment that ensures the independence and impartiality of the assignment process, from the list of approved IROs compiled and maintained by the Montana Commissioner of Securities and Insurance to conduct the external review. In making the assignment, The Plan will consider whether an IRO is qualified to conduct the particular external review based on the nature of the health care service or treatment that is the subject of the adverse benefit determination or final internal adverse benefit determination. The Plan will also take into account other circumstances, including conflict of interest concerns.
Assignment of an IRO. If the request is eligible for external review, The Plan will immediately assign an IRO on a random basis or using another method of assignment that ensures the independence and impartiality of the assignment process, from the list of approved IROs compiled and maintained by the Commissioner of Securities and Insurance, to conduct the external review. In making the assignment, The Plan will consider whether an IRO is qualified to conduct the particular expedited external review based on the nature of the health care service or treatment that is the subject of the adverse benefit determination or final internal adverse benefit determination and will also take into account other circumstances, including conflict of interest concerns. Within 1 business day after assignment of the IRO, The Plan will notify the Member or the Member’s authorized representative, in writing, that The Plan has initiated an external review and that the Member or the Member’s authorized representative may submit additional information to the IRO for the IRO’s consideration in its external review.
Assignment of an IRO. If the request is eligible for external review, The Plan will within 1 business day assign an IRO on a random basis or using another method of assignment that ensures the independence and impartiality of the assignment process, from the list of approved IROs compiled and maintained by the Commissioner of Securities and Insurance, to conduct the external review. In making the assignment, The Plan will consider whether an IRO is qualified to conduct the particular external review based on the nature of the health care service or treatment that is the subject of the adverse benefit determination or final internal adverse benefit determination and will also take into account other circumstances, including conflict of interest concerns. Within 1 business day of assigning the IRO, The Plan will notify the Member or the Member’s authorized representative in writing that The Plan has initiated an external review and that the Member or the Member’s authorized representative may submit additional information to the IRO within 10 business days following the date of receipt of the notice, for the IRO’s consideration in its external review. The IRO may accept and consider additional information submitted after the 10 business days.
Assignment of an IRO. If a request is eligible for expedited external review, The Plan will assign an IRO pursuant to and in compliance with the independence and other selection requirements set forth in the Assignment of an IRO paragraph, Standard External Review Procedures section. The Plan will transmit all documents and information considered in making the adverse benefit determination or final internal adverse benefit determination to the assigned IRO in as expeditious of a manner as possible (including by phone, facsimile, or electronically).