As we move forward in implementing ACA regulations, there is a requirement for plans to have in place an external review process by January 1, 2012.
- How are coalitions and their members approaching this requirement?
- Are coalitions assisting their members in this process and if so, please provide examples of how you are doing this?
- Are your members including this as part of their TPA/ASO contracts and amending their vendor documents?
- What are the coalitions and their members seeing as a price range for this service?
- Are you finding enough external review agencies to meet your needs?
[General statement of requirement: The group health plan must assign an independent review organization (IRO) that is accredited by the Utilization Review Accreditation Committee (URAC) or by a similar nationally recognized accrediting organization, to conduct the external review. In order to prevent against bias and ensure independence, the plan must contract with at least three (3) IROs for assignments under the plan and rotate claim assignments among them (or incorporate other independent, unbiased methods for selection of IROs, such as random selection). The plan is prohibited from providing the IRO any financial incentives based on the likelihood that the IRO will support the denial of benefits.]
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