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 27-8-29-12, the Contractor must 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 the Contractor’s decision to a State fair hearing. 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) within one hundred and twenty (120) calendar days of receipt of the appeal decision. The IRO shall render a decision within fifteen (15) business to uphold or reverse the Contractor’s decision. The determination made by the IRO is binding on the Contractor.

External Review by Independent Review Organization. In accordance with IC 27-13-10.1-1 and IC 27-8-29-121, the Contractor must shall maintain an external grievance procedure for the resolution of decisions related to an adverse utilization review determination, an adverse determination of medical necessity 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 the Contractor’s a Contractor decision to a State fair hearing. A member may seek external review by an IRO, and such process may run concurrently with 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) within one hundred and twenty (120) calendar days of receipt of the appeal decision). The IRO shall render a decision within fifteen (15) business to uphold or reverse the Contractor’s decisiondecision within seventy-two (72) hours for an expedited appeal, or fifteen (15) business days for a standard appeal. The determination made by the IRO independent review organization is binding on the Contractor.