<?xml version='1.0' encoding='utf-8'?>
<regulation prefix="Regulation" num=".03" citation="COMAR 10.67.13.03" title_num="10" subtitle_num="67" chapter_num="13" heading="Use of Independent Review Organizations.">
  <paragraph num="A.">
    <text>The Department shall procure the services of an IRO to make determinations of medical necessity on provider complaints regarding adverse decisions.</text>
  </paragraph>
  <paragraph num="B.">
    <text>An IRO that contracts with the Department shall assure, in accordance with its contract with the Department, the:</text>
    <paragraph num="(1)">
      <text>Timeliness and quality of the reviews;</text>
    </paragraph>
    <paragraph num="(2)">
      <text>Qualifications and independence of the IRO and expert reviewers; and</text>
    </paragraph>
    <paragraph num="(3)">
      <text>Confidentiality of medical records and review materials, consistent with federal and State laws.</text>
    </paragraph>
  </paragraph>
  <paragraph num="C.">
    <text>An IRO designated by the Department shall have the authority to conduct the following functions:</text>
    <paragraph num="(1)">
      <text>Obtaining all case information relative to the complaint from the MCO pursuant to time frames established by the Department;</text>
    </paragraph>
    <paragraph num="(2)">
      <text>Assigning an expert reviewer for review of an adverse decision;</text>
    </paragraph>
    <paragraph num="(3)">
      <text>Performing conflicts checks relative to the independent review organization and the expert reviewer assigned to review the adverse decision;</text>
    </paragraph>
    <paragraph num="(4)">
      <text>Communicating procedural rules, as approved by the Department, and other information regarding appeals to the parties;</text>
    </paragraph>
    <paragraph num="(5)">
      <text>Rendering a timely final decision in accordance with Regulation .06F of this chapter.</text>
    </paragraph>
  </paragraph>
</regulation>