Information Regarding Independent Review Organizations (IRO)
- How do I request a review by an IRO
- How do I find a certified IRO?
- How do I become an IRO?
- What are my responsibilities as an IRO?
- Renewals and Application Updates
- How do I file a complaint?
- IRO Decisions
Applicable Law & Rules
The Texas Department of Insurance (TDI), Managed Care Quality Assurance Office (MCQA), issues certifications for IROs. Once an IRO is certified to perform independent reviews to determine medical necessity, the MCQA Office adds the IRO to the Certified IRO list online. If you need additional assistance locating an IRO, contact MCQA at 1-866-554-4926.
The purpose of this section is to help you apply to become a certified IRO in the state of Texas. In this segment you will find links to the application, associated forms, and applicable rules.
Original application: Entity is applying for original certification as an IRO.
- Applicant must complete all items of the IRO application form LHL006. Do not leave any spaces blank - indicate "NA" if appropriate.
- Label each attachment. For example, Exhibit 3: Attachment B, Certification of Compliance.
- Filing Fee of $1000.00 must be included and must be made payable to the Texas Department of Insurance. The fee is non-refundable.
Special Instructions Regarding Biographical Affidavits and Addendum:
- Applicant is required to submit a biographical affidavit (NAIC Form No. 11) and addendum (FIN589) for each director, officer, and executive of the Applicant.
- All applicants for licensure must comply with 28 TAC §§1.501-1.509, including 28 TAC §1.504, Fingerprint Requirement. (Applicant Fingerprinting Instructions)
- Applicant is required to fill out the IRO Application Form LHL006
The purpose of this section is to identify the responsibilities of an IRO. An IRO determines medical necessity and appropriateness of health care delivered or proposed to be delivered. The IRO is responsible for assigning the case to an appropriate specialty reviewer who certifies he/she has no conflict of interest. In this segment, you will find links to 28 TAC Chapter 12, which governs the independent review process. You will also find timeframes for decisions, templates for decisions and the Division of Workers' Compensation Disability Management page.
- Timeframes for Decisions
- Notice of IRO Decisions Templates:
- Certification of independence and qualifications of the Reviewer - TDI form FIN582
- Disability Management Homepage
Renewal: IRO is applying for renewal of its existing certification. An IRO must apply for renewal of the certificate every two years after the date of certification. Please remember that if the renewal application is not received by the Department before or on the date of expiration, the certification will automatically expire and the IRO must submit a new original application and the filing fee for an original application. Independent reviews will not be assigned to an independent review organization during the 30 days prior to the anniversary date of the issuance of the independent review organization’s certificate of registration unless the completed renewal application form has been received by the department. The IRO must submit:
- the completed IRO application form;
- the renewal fee of $400.00 payable to the Texas Department of Insurance. The fee is non-refundable;
- a certification that no material changes exist that have not already been filed with the department; and
- a certification of primary office
Update/Changes to Original Application: After issuance of an IRO’s certification, the IRO must file with TDI material changes to the information required in the IRO application, including changes relating to physicians and provider performing independent review, or the last renewal application not later than the 30th day after the date on which the change takes effect. For example: new officers and directors; changes in the organizational structure; changes in contractual relationships; and changes in the independent review plan.
IRO should provide a list and explanation, on company letterhead and signed by an authorized representative, of any material changes to the information disclosed in an original or renewal application within 30 days of the change taking effect. (i.e. contact name has changed since issuance of certificate). There is no fee to update/change an original application.
If changes have been made to previously filed exhibits, attachments, or documents, the IRO must submit the information for review and approval. The IRO must identify those items in the application form that are being updated or changed and must reference the appropriate exhibits, attachments, or documents to indicate the requirement that is being updated or changed. Submit a redline version of the material changes by striking through the superseded language and underlining the new language (e.g., strikethrough and underline).
- The IRO application form LHL006 is utilized to submit IRO renewals and updates.
For more information, contact:
Last updated: 06/28/2016