External review documents in the context of health insurance are typically conducted by Independent Review Organizations (IROs) that meet specific requirements. These organizations are approved by state departments of insurance or the federal government. Here are some key points regarding the requirements and process:
Requirements for Conducting External Reviews
- Approval: The IRO must be approved by the state department of insurance or the federal government. For instance, in states with a federally-compliant external review process, the federal government, through the Department of Health and Human Services (HHS), can oversee the process using contracted IROs like MAXIMUS Federal Services.
- Independence: The reviewer must be independent and unbiased, ensuring that the decision is not influenced by the insurer or other financial interests.
- Expertise: The reviewers typically need to have relevant medical expertise in the area of dispute. For example, if the issue involves a medical necessity determination, the reviewer should have expertise in that medical field.
Conducting External Reviews
- Eligibility: External reviews can be requested for certain types of denials, such as those involving medical judgment or determinations that a treatment is experimental.
- Timing: Requests for external reviews must be made within four months of receiving the final adverse benefit determination from the health insurer.
- Filing Process: Consumers can file a request through various methods, including online portals, mail, fax, or email, depending on the state or federal process being used.
Specifics on Third-Party Verifiers
- Authorization: Any third-party verifier, such as an IRO, must be authorized by the relevant state or federal authorities.
- Compliance with Regulations: These organizations must comply with federal consumer protection standards and state regulations where applicable.
In summary, while third-party verifiers can conduct external reviews, they must meet specific requirements and be authorized by relevant authorities to ensure impartiality and expertise.
Original article by NenPower, If reposted, please credit the source: https://nenpower.com/blog/can-external-review-documents-be-conducted-by-any-third-party-verifier-or-are-there-specific-requirements/
