NAIRO’s External Review Regulations

NAIRO’s External Review Regulations

The National Association of Independent Review Organizations (NAIRO) was formed in 20012 by a group of URAC-accredited Independent Review Organizations (IROs). The group’s purpose is to provide uniform regulations from state to state by simplifying the regulated independent review organization application process and independent medical peer review requirements among the states. The regulations are a result of the Patient Protection and Affordable Care Act and related to the Department of Labor, the Department of Health and Human Services, and the Department of Treasury.

Original source – NAIRO website

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NAIRO’s external reviews apply to:

1. Non-grandfathered plans
2. States whose external review standards don’t meet the minimum qualifications set forth by the Federal External Review Process
3. States who haven’t adopted a state external review process.
4. States who voluntarily adopt the Federal Review Process

The Federal External Review process requires plans to contract with at least three URAC-accredited IROs to conduct the external review in order to ensure unbiased and independent decisions.

Following are the requirements set forth for standard reviews (external):

1. Allow a claimant to file a request for an external review for up to four months after the date of receipt of a notice of an adverse benefit determination.
2. Within five business days of receipt of the external review request, the plan must complete a preliminary review of the request to determine:
   1. The claimant was covered under the plan at the time the service was requested
   2. The adverse benefit determination does not relate to the claimant’s failure to meet eligibility requirements
   3. The claimant has exhausted the plan’s internal appeals process unless the claimant is not required to exhaust the internal appeals process under the regulations
   4. The claimant has provided all necessary information and forms to process an external review
3. Within one business day after completing the preliminary review, the plan must issue a written notification to the claimant.
4. Assign an accredited IRO to conduct the external review
5. The IRO must review the claim de novo and not bound by any decisions or conclusions reached during the plan’s internal claims and appeals process.
6. If the IRO reverses the plan’s adverse benefit determination, the plan must immediately provide coverage or payment for the claim.

Self-funded health plans must also allow for expedited reviews under certain circumstances. The process for an expedited review mirrors the process for a standard review except that the plan must immediately determine if a request is eligible for external review and must provide all necessary documents and information to the assigned IRO electronically or by telephone or facsimile or any other available expeditious method.

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