Important Notice to Insurers About External Review

INSURER’S STEP ONE:

Determine if expedited

Statute ORS 745.861 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.

INSURER’S STEP TWO:

Forward request

Upon receipt of a request for an external review, either expedited or standard, the insurer is to fill out one of the External Review Request forms:

• Complete electronic form and submit or
• Fax External Review Request form to
  ATTN: Lisa Dixon at (503) 378-4351 or
• E-mail External Review Request form to exreview.ins@state.or.us
• If you have questions call Lisa Dixon at (503) 947-7267 or leave a message on the external review voice mailbox at (503) 947-7276.

Insurers must forward requests within two days. Due to the three day limit for the entire expedited review procedure, insurers are to forward all expedited requests immediately upon receiving the request.

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.

INSURER’S STEP THREE:

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 fax or overnight the records immediately.

The insurer must send to the patient or the patient's representative an index or listing of all of the documents in his or her record that were sent to the assigned IRO. After receiving the index, the patient may forward directly to the IRO items that are important to the case that are not listed on the index within seven (7) days of the request of external review from the insurer.

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.

INSURER’S STEP FOUR:

Respond to other IRO requests

If contacted by the IRO for additional information, the insurer must cooperatively respond to all such requests as quickly as possible.

For further information or clarification, contact Rhett Stoyer, at rhett.b.stoyer@state.or.us or (503) 947-7208.