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IDAPA 18.04.01

Total Codified Sections: 8

Title 41, Chapters 2 and 59, Idaho Code. (3-31-22)

IDAPA 18.04.01.001 - Scope

This rule sets forth uniform requirements to be followed by health carriers and independent review organizations in implementing external review procedures in accordance with Title 41, Chapter 59, Idaho Code. (3-31-22)

IDAPA 18.04.01.010 - Definitions

The definitions set forth in Title 41, Chapter 2 and 59 are applicable to these rules. In addition, the following term has the following meaning: (3-31-22)

  1. URAC. The nationally recognized private health care accreditation organization based in Washington, D.C., that accredits independent review organizations. (3-31-22)

IDAPA 18.04.01.020 - Notice Of Right To External Review

  1. Disclosure to Covered Persons. Health carriers will provide ex ternal review procedures to covered persons as per Chapter 59, Title 41 and in manner as directed by the Department. (3-31-22)

  2. Notice to Covered Person. In accordance with Chapter 59, Title 41: (3-31-22)

    a. The written notice of the covered person's right to request an external review is to use the form posted on the Department's website or is substantially similar. Health carriers are to submit notice forms to the Director for approval; and (3-31-22)

    b. The written notice sent by the health carrier as prescribed by this subsection is to include an authorization form to disclose protected health information in compliance with the federal regulation and in a manner as approved by the Department. (3-31-22)

IDAPA 18.04.01.021 - Request For External Review

  1. Request Form. The form for a covered person to request an external review will be available from the Department and will be posted on the Department's web site. (3-31-22)

  2. Authorization Form. The covered person's request for an external review is to include an authorization form to disclose protected health information prescribed in Paragraph 020.02.b. (3-31-22)

IDAPA 18.04.01.022 - Health Carrier Notice Of Initial Determination Of An External Review

REQUEST. Health carriers are to use the form posted on the Department's website or one substantially similar as determined by the Department. (3-31-22)

IDAPA 18.04.01.023 - Approval Of Independent Review Organizations

  1. Application for Registration. Independent review organizations need to apply to the department on the requisite form and pay the applicable fees, as set forth at IDAPA 18.01.02, to be registered to perform external reviews. (3-31-22)

  2. Notice to Director. (3-31-22)

    a. An independent review organization will notify the Director in writing within thirty (30) days of the date the independent review organization is no longer accredited by a nationally recognized private accrediting entity or no longer satisfies the minimum requirements established under Title 41, Chapter 59, Idaho Code and this rule. (3-31-22)

    b. Any change in the independent review organization's schedule of costs and fees for performing external reviews need to be submitted to the Director at least sixty (60) days before the effective date of the change. (3-31-22)

  3. Termination of Approval. The Director may immediately terminate approval of an independent review organization if the independent review organization no longer satisfies the requirements of Title 41, Chapter 59, Idaho Code, and this rule. Notice of termination will be in writing to the independent review organization and such organization will be deleted from the list of organizations approved to perform external reviews. If the independent review organization is performing an external review at the time of termination, the independent review organization will cease performing that review and immediately forward all information and documentation to the Director. (3-31-22)

IDAPA 18.04.01.024 - Voluntary Election By Erisa Plan Administrator

  1. Written Notice and Compliance. If a single employer self-funded ERISA employee benefit plan administrator or designee voluntarily elects to comply with Title 41, Chapter 59, Idaho Code, the administrator or designee will comply with all provisions of Title 41, Chapter 59, Idaho Code, and this rule, as if it were a health carrier and, in a manner, as approved by the department on forms posted on the Department's website. (3-31-22)