IRO Review Sample Clauses
The IRO Review clause establishes the process by which an Independent Review Organization (IRO) evaluates specific disputes or determinations, typically in the context of healthcare claims or compliance matters. Under this clause, when parties disagree on a decision—such as the denial of a medical claim or the outcome of an audit—an impartial third-party IRO is engaged to review the relevant information and render a binding or advisory opinion. This mechanism ensures that disputes are resolved fairly and objectively, providing an alternative to litigation and helping to maintain trust between the parties involved.
IRO Review. With respect to LifePoint's Laboratory Claims Review, the IRO will prepare a report documenting the IRO's findings with respect to the following procedures:
A. The IRO will obtain LifePoint's workpapers and perform procedures to test concurrence with the criteria set forth in section III.D.2.
B. The IRO will select a random sample of a minimum of 10% of the Items reviewed pursuant to the Laboratory Review and re-perform LifePoint's workplan steps.
IRO Review. For each of the three Reporting Periods, the IRO shall perform a review of PANF’s Patient Assistance Related Functions and prepare an IRO Review Report as outlined in Appendix B to this IA, which is incorporated by reference. Each annual IRO Review shall cover the applicable calendar year (e.g., the IRO Review for the first Reporting Period shall cover calendar year 2020.)
IRO Review. The IRO Review shall consist of three components: 1) Selection of Facilities; 2) an Internal Compliance Audit Review; and 3) a Claims Review. The IRO shall perform the IRO Review annually to cover each of the five Reporting Periods. The IRO shall perform all components of each IRO Review.
IRO Review. The IRO Review shall consist of three components:
IRO Review. For each of the three Reporting Periods, the IRO shall perform a review of PSI’s Patient Assistance Related Functions and prepare an IRO Review Report as outlined in Appendix B to this IA, which is incorporated by reference. Each annual IRO Review shall cover the applicable calendar year (e.g., the IRO Review for the first Reporting Period shall cover calendar year 2020.)
IRO Review. As part of the Promotional and Product Services Transactions Review, the IRO shall evaluate InterMune’s processes relating to its Medical Affairs Inquiries Database. Specifically, the IRO shall select a random sample of 50 Inquiries from among the Inquiries reflected in the Medical Affairs Inquiries Database for each Reporting Period. One half of the Inquiries reviewed by the IRO shall be Inquiries for which InterMune conducted an Off-Label Review, and the other half shall be Inquiries for which InterMune did not conduct an Off-Label Review. For each Inquiry reviewed, the IRO shall determine:
(i) whether each item of information listed above in Section III.A.1.a is reflected in the Medical Affairs Inquiries Database for each reviewed Inquiry; and
(ii) for each Inquiry for which the Compliance Officer conducted an Off Label Review, the basis for suspecting that improper off-label promotion may have occurred; the steps undertaken as part of the Off-Label Review; the findings of the Compliance Officer as a result of the Off-Label Review; and any follow-up actions taken by InterMune based on the Compliance Officer’s findings.
IRO Review. The IRO shall conduct a review of Third-Party Liability Claims covering each Reporting Period, as set forth below.
a. The IRO will review a statistically valid random sample of at least 500 randomly selected Third-Party Liability Claims from the sample of Third-Party Liability Claims reviewed by the Quality Team as part of the Post-Processing Review.
b. As part of its review, the IRO shall determine the Error Rate applicable to the Third-Party Liability Claims reviewed. The Error Rate shall be used to determine whether a root cause analysis, as described below, will be performed.
c. The IRO shall also determine the Rejection Rate applicable to the Third-Party Liability Claims reviewed. The Rejection Rate will be used solely for informational purposes to identify potential problems on the applicable PBM Platform and to consider related corrective actions.
d. The IRO shall determine the Error Rate and Rejection Rate applicable to the Third-Party Liability Claims as originally processed, prior to any reprocessing done by the Quality Team pursuant to Section A.6, below.