The IRO application form requires information that is necessary
for the commissioner to determine whether an applicant is qualified
for a certificate of registration as an IRO under Insurance Code §4202.004,
including:
(1) a summary of the independent review plan that meets
the requirements of §12.201 of this chapter, which must include:
(A) a summary description of review criteria and review
procedures to be used to determine medical necessity or appropriateness
of health care;
(B) a summary description of review criteria and review
procedures to be used to determine the experimental or investigational
nature of health care;
(C) a certification signed by the IRO's medical director
that the review criteria and review procedures to be applied in review
determinations are established with input from appropriate health
care providers and approved by physicians under §12.201(3) of
this chapter;
(D) procedures ensuring that the information regarding
the reviewing physicians and providers is updated under §12.111(a)
of this chapter to ensure the independence of each health care provider
or physician making review determinations; and
(E) a summary description of criteria and review procedures
to be used by the medical director to conduct quality assurance audits
under §12.202(c)(2) of this chapter.
(2) copies of policies and procedures that ensure that
all applicable state and federal laws to protect the confidentiality
of medical records and personal information are followed. These procedures
must comply with §12.208 of this chapter;
(3) a certification, signed by an officer, director,
or owner of the IRO, that the IRO and any party that performs an IRO
function through contracts and subcontracts will comply with Insurance
Code Chapter 4202 and this chapter. The certification must include
a statement that the IRO is responsible for ensuring that all contracted
and subcontracted functions are performed according to Insurance Code
Chapter 4202 and this chapter, subject to the IRO's oversight and
monitoring, and that the IRO retains ultimate responsibility for compliance;
(4) a description of personnel and their credentials
and a completed profile for each physician and provider, as described
in §12.202 of this chapter that must include:
(A) the credentialing and recredentialing procedures
used by the IRO applicant to verify physician and provider credentials
and the computer processes, electronic databases, and records, if
any, used to make the verification; and
(B) the credentialing software used by the applicant
for managing the processes, databases, and records described in subparagraph
(A) of this paragraph;
(5) a description of hours of operation and how the
IRO may be contacted after hours and during weekends and holidays,
as set out in §12.207 of this chapter;
(6) a description of the applicant's use of communications,
records, and computer processes to manage the independent review process;
(7) a description and evidence of accreditation from
a nationally recognized accrediting organization, if any, that imposes
requirements for accreditation that are the same as, substantially
similar to, or more stringent than the department's requirements for
a certificate of registration. Evidence of accreditation will be maintained
in the department's file for the IRO applicant, and the applicant
may request expedited approval of the certificate of registration
with evidence of accreditation from a nationally recognized accrediting
organization;
(8) the organizational information, documents, and
all amendments that must include:
(A) written evidence that the applicant is incorporated
in this state, which may include a copy of the Certificate of Formation
from the Texas Secretary of State;
(B) for an applicant that is publicly held, the name,
address, and Federal Employer Identification Number (EIN) of each
stockholder or owner of more than 5 percent of any stock or options;
(C) a chart showing the internal organizational structure
of the applicant's management and administrative staff;
(D) a chart showing contractual arrangements of the
applicant, including all contracts between the applicant and any person
and all subcontracts with other persons to perform any business or
daily functions of an IRO; and
(E) copies of the contract and subcontract with any
person who will perform IRO functions on behalf of the applicant.
All contracts and subcontracts must include at a minimum:
(i) a provision that the contracted or subcontracted
party will comply with §12.208 of this chapter;
(ii) a provision that the applicant is responsible
for ensuring that all contracted and subcontracted functions are performed
under Insurance Code Chapter 4202 and this chapter, subject to the
applicant's oversight and monitoring;
(iii) a provision that the applicant retains ultimate
responsibility for compliance; and
(iv) a provision that, on request, the contracted party
will provide the applicant with data necessary for the applicant to
comply with department requests for information about IRO functions;
(9) the name of any holder of bonds or notes of the
applicant that exceed $100,000;
(10) the name, address, EIN, and type of business of
each corporation or other organization that the applicant controls
or is affiliated with and the nature and extent of the affiliation
or control, and a chart or list clearly identifying the relationships
between the applicant and any affiliates;
(11) biographical information about officers, directors,
and executives, including information requested in the biographical
affidavit as required in §12.102(b) of this chapter:
(A) the applicant must submit a complete set of fingerprints
for each director, officer, and executive of the applicant and for
each owner or shareholder of the applicant, or if the applicant is
publicly held, each owner or shareholder of more than 5 percent of
any of the applicant's stock or options as described by Insurance
Code §4202.004(a)(1), in compliance with §1.503 and §1.504
of this title;
(B) the applicant must submit the name and biographical
information for each director, officer, and executive of the applicant
and of any entity listed under paragraph (10) of this section and
a description of any relationship the named individual has that represents
revenue equal to or greater than 5 percent of that individual's total
annual revenue or which represents a holding or investment worth $100,000
or more in any of the following entities:
(i) a health benefit plan;
(ii) a health maintenance organization;
(iii) an insurer;
(iv) a utilization review agent;
(v) a nonprofit health corporation;
(vi) a payor;
(vii) a health care provider;
(viii) another IRO; or
(ix) a group representing any of the entities described
by clauses (i) - (viii) of this subparagraph.
(C) the applicant must identify any relationship between
the applicant and any affiliate or other organization in which an
officer, director, or employee of the applicant holds a 5 percent
or more interest;
(D) the applicant must submit a list of any currently
outstanding loans or contracts to provide services between the applicant,
affiliates, or any other person relating to any functions performed
by or on behalf of the applicant;
(12) documentation from the comptroller demonstrating
the applicant's good standing and right to transact business in this
state;
(13) for an application for a certificate of registration
or renewal of a certificate of registration as an IRO in this state
made on or after July 7, 2015, a sworn statement from an officer of
the organization that:
(A) the applicant's primary office included on the
IRO application form is located and maintained at a physical address
in this state. As a condition of holding a certificate of registration
to conduct the business of independent review in this state, an IRO
must locate and maintain its primary office at a physical address
in this state;
(B) the primary office is equipped with a computer
system capable of:
(i) processing requests for independent review; and
(ii) accessing all electronic records related to the
review and the independent review process;
(C) all records are maintained electronically and will
be made available to the department on request;
(D) in the case of an office located in a residence,
the working office must be located in a room set aside for independent
review business purposes and in a manner to ensure confidentiality;
and
(E) medical records are maintained according to §12.208
of this chapter;
(14) the percentage of the applicant's revenues that
are anticipated to be derived from independent reviews conducted;
and
(15) a disclosure of any enforcement actions related
to the provision of medical care or conducting of medical reviews
taken against a person subject to the fingerprint requirements under §1.503
and §1.504 of this title.
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