Common use of External Review by Independent Review Organization Clause in Contracts

External Review by Independent Review Organization. In accordance with IC 27-13-10.1-1 and IC 27-8-29-1, the Contractor shall maintain an external grievance procedure for the resolution of decisions related to an adverse utilization review determination, an adverse determination of medical necessity, or a determination that a proposed service is experimental or investigational. An external review does not inhibit or replace the member’s right to appeal a Contractor decision to a State fair hearing. Within thirty-three (33) calendar days from the date of the Contractor’s decision, a member, or a member’s representative may file a written request for a review of the Contractor’s decision by an independent review organization (IRO). The IRO shall render a decision to uphold or reverse the Contractor’s decision within seventy-two (72) hours for an expedited appeal, or fifteen (15) business days for a standard appeal. The determination made by the independent review organization is binding on the Contractor.

External Review by Independent Review Organization. In accordance with IC 27-13-10.1-1 and IC 27-8-29-1, the Contractor shall maintain an external grievance procedure for the resolution of decisions related to an adverse utilization review determination, an adverse determination of medical necessity, or a determination that a proposed service is experimental or investigational. An external review does not inhibit or replace the member’s right to appeal a Contractor decision to a State fair hearing. Within thirty-three (33) calendar days from the date of the Contractor’s decision, a member, or a member’s representative may file a written request for a review of the Contractor’s decision by an thirty- independent review organization (IRO). The IRO shall render a decision to uphold or reverse the Contractor’s decision within seventy-two -two (72) hours for an expedited appeal, or fifteen (15) business days for a standard appeal. The determination made by the independent review organization is binding on the Contractor.