Common use of IRO Qualifications Clause in Contracts

IRO Qualifications. The IRO shall: 1. assign individuals to conduct the Quarterly Claims Review who have expertise in the Medicare and state Medicaid program requirements applicable to the claims being reviewed; 2. assign individuals to design and select the Quarterly Claims Review sample who are knowledgeable about the appropriate statistical sampling techniques; 3. assign individuals to conduct the coding review portions of the Quarterly Claims Review who have a nationally recognized coding certification and who have maintained this certification (e.g., completed applicable continuing education requirements); 4. assign licensed nurses or physicians with relevant education, training and specialized expertise (or other licensed health care professional acting within their scope of practice and specialized expertise) to make the medical necessity determinations required by the Quarterly Claims Review; and 5. have sufficient staff and resources to conduct the reviews required by the IA on a timely basis.

IRO Qualifications. The IRO shall: 1. assign individuals to conduct the Quarterly Claims Review who have expertise in the Medicare Medicare, state Medicaid, and state Medicaid TRICARE program requirements applicable to the claims being reviewed; 2. assign individuals to design and select the Quarterly Claims Review sample who are knowledgeable about the appropriate statistical sampling techniques; 3. assign individuals to conduct the coding review portions of the Quarterly Claims Review who have a nationally recognized coding certification and who have maintained this certification (e.g., completed applicable continuing education requirements); 4. assign licensed nurses or physicians with relevant education, training and specialized expertise (or other licensed health care professional professionals acting within their scope of practice and specialized expertise) to make the medical necessity determinations required by the Quarterly Claims Review; and 5. have sufficient staff and resources to conduct the reviews required by the IA CIA on a timely basis.

IRO Qualifications. The IRO shall:shall:‌‌ 1. assign individuals to conduct the Quarterly Claims Review who have expertise in the Medicare and state Medicaid program requirements applicable to the claims being reviewed;reviewed;‌ 2. assign individuals to design and select the Quarterly Claims Review sample who are knowledgeable about the appropriate statistical sampling techniques;techniques;‌ 3. assign individuals to conduct the coding review portions of the Quarterly Claims Review who have a nationally recognized coding certification and who have maintained this certification (e.g., completed applicable continuing education requirements);requirements);‌‌ 4. assign licensed nurses or physicians with relevant education, training and specialized expertise (or other licensed health care professional acting within their scope of practice and specialized expertise) to make the medical necessity determinations required by the Quarterly Claims Review; andand‌‌ 5. have sufficient staff and resources to conduct the reviews required by the IA on a timely basis.basis.‌

IRO Qualifications. The IRO shall: 1. assign individuals to conduct the Quarterly Claims Review who have expertise in the Medicare and state Medicaid program requirements applicable to the claims being reviewed; 2. assign individuals to design and select the Quarterly Claims Review sample who are knowledgeable about the appropriate statistical sampling techniques; 3. assign individuals to conduct the coding review portions of the Quarterly Claims Review who have a nationally recognized coding certification and who have maintained this certification (e.g., completed applicable continuing education requirements); 4. assign licensed nurses or physicians with relevant education, training and specialized expertise (or other licensed health care professional acting within their scope of practice and specialized expertise) to make the medical necessity determinations required by the Quarterly Claims Review; and 5. have sufficient staff and resources to conduct the reviews required by the IA on a timely basis.