20-2538. Independent review
organizations
A. Pursuant to title 41, chapter 23, the director shall procure as many independent
review organizations as necessary and practicable to perform the independent medical
reviews described in section 20-2537.
B. Through the procurement process the director shall ensure that any procured
independent review organization uses physicians or other health care professionals who
are licensed pursuant to title 32, chapter 7, 8, 11, 13, 14, 17, 19, 19.1 or 29 or out of
state physicians or other health care professionals who are licensed in another state and
who are not licensed in this state, who are board certified or board eligible by the
appropriate American medical specialty board and who are in the same or a similar scope
of practice as a physician or another health care professional who is licensed pursuant
to title 32, chapter 7, 8, 11, 13, 14, 17, 19, 19.1 or 29 or an out of state physician or
another health care professional who is licensed in another state and who is not licensed
in this state and who typically manages the medical condition, procedure or treatment
under review.
C. The independent review organization and its individual reviewer shall not have a
substantial interest in the member, provider or health care insurer involved in the
particular case under review or any other conflict of interest that will preclude the
reviewer from making a fair and impartial decision. The individual reviewer shall not be
a policyholder or insured member of a company whose case is being reviewed.
D. An out of state physician or another health care professional who is licensed in
another state and who is not licensed in this state in a field substantially similar to
the laws of this state applicable to physicians or other health care professionals who
are licensed under title 32, chapter 7, 8, 11, 13, 14, 16, 17, 19, 19.1 or 29 and who are
certified or board eligible by the appropriate American medical specialty board may serve
as an independent reviewer for the procured independent review organization and that
provider's analysis, assessment or decision for the independent review organization does
not constitute the practice of medicine or any other health care profession in this
state.
E. The director, any procured independent review organization or any independent
reviewer acting in good faith is not liable for the analysis, assessment or decision of
any case reviewed pursuant to this article.
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