External review of health care decisions
Determine if expedited
743.857(5) requires that insurers forward all requests for external review to the Oregon Insurance Division. Upon receipt of a written request from a patient or patient's representative for external review, the insurer must determine whether the request warrants an expedited review.
An expedited review is warranted when any health care professional who has a clinical relationship with the patient states that the patient may experience serious danger or a deterioration in quality of life if required to wait 30 days, the length of time for a standard review.
Upon receipt of a request for an external review, either expedited or standard, the insurer must:
- Complete electronic referral form and submitor
- Fax referral form to
ATTN: Rhett Stoyer at 503-378-4351, or
- Email referral form to firstname.lastname@example.org
Deadlines for referrals
- Insurers must forward standard referrals within two days.
- Insurers must forward expedited review referrals immediately.
The independent review organization's (IRO) first task is to determine whether the case is eligible for external review per insurance policy and state regulations.
Index and send patient’s record
The Oregon Insurance Division will mail and fax the name and contact information of the randomly chosen IRO to the insurer, with instructions to send or fax the patient's medical record and additional information to the IRO. For expedited reviews, the insurer must immediatley fax or overnight the records.
NOTE: If either the insurer or the enrollee knows of a conflict of interest with the IRO assigned to the case, they must provide evidence to the Insurance Division within three days of receiving the IRO notification letter. Another IRO will be assigned.
Respond to IRO requests
If contacted by the IRO for additional information, the insurer must cooperatively respond to all such requests as quickly as possible.