Independent Review Organization (IRO definition

Independent Review Organization (IRO means independent third parties who conduct external review of a service denied by a health plan. Preferred Administrators will use IROs accredited by URAC or by a similar nationally-recognized accrediting organization to conduct the external review.
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Independent Review Organization (IRO means an impartial, certified health entity engaged by the Commissioner or the Director to review any adverse grievance decision made by Guardian.
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Independent Review Organization (IRO means an organization not affiliated with GHC-SCW that is certified by the Commissioner of Insurance to offer clinical expertise, confidential and unbiased decision making regarding GHC-SCW’s Adverse Determinations based on Medical Necessity and/or Experimental, Investigational, or Unproven Services.
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Examples of Independent Review Organization (IRO in a sentence

  • An explanation that you may ask for an external review with an Independent Review Organization (IRO) not associated with Blue Cross and Blue Shield if your appeal was denied based on any of the reasons below.

  • The Independent Review Organization (IRO) will notify the Insured Person of the determination within 72 hours.

  • If Your claim is not eligible for external review, we will outline the reasons it is ineligible in the notice, and provide contact information for the Department of Labor’s Employee Benefits Security Administration (toll-free number 1-866-444-EBSA (3272)) and or state consumer ombudsman as appropriate.3. Referral to Independent Review Organization (IRO).

  • Denials based on Experimental/Investigational services and supplies are Adverse Determinations and are subject to the utilization review process, including reviews by an Independent Review Organization (IRO) as described in the Complaint and Appeals section.

  • When a request is complete and eligible for an EER, the Commissioner shall immediately assign an Independent Review Organization (IRO) from the Commissioner’s approved list and notify the Company of the name of the assigned IRO.

  • Denials based on Experimental/Investigational services and supplies are Adverse Determinations and are subject to the utilization review process, including reviews by an Independent Review Organization (IRO) as described in the COMPLAINT AND APPEALS section.

  • Denials based on Experimental/Investigational services and supplies are Adverse Determinations and are subject to the utilization review process, including reviews by an Independent Review Organization (IRO) as described in the Complaint and Appeal Procedures section.5. Any charges resulting from the failure to keep a scheduled visit with a Participating Provider or for acquisition of medical records.6. Special medical reports not directly related to treatment.

  • An Expedited External Appeal is a request for immediate review, by an Independent Review Organization (IRO).

  • Expedited External Appeal – A request for immediate review, by an Independent Review Organization (IRO), of an initial Adverse Benefit Determination, which involves any of the following: A.

  • Assign an Independent Review Organization (IRO) from the Commissioner’s approved list; b.


More Definitions of Independent Review Organization (IRO

Independent Review Organization (IRO means an entity that conducts independent external reviews ofadverse benefit determinations and final internal adverse benefit determinations. MMail order pharmacy means a pharmacy that provides covered mail order pharmacy services, as defined by Humana, and delivers covered prescriptions or refills through the mail to covered persons. Medicare means a program of medical insurance for the aged and disabled, as established under Title 18 of the Social Security Act of 1965, as amended. NNon-participating pharmacy means a pharmacy that has NOT signed a direct agreement with Humana or has NOT been designated by Humana to provide covered pharmacy services or covered mail order pharmacy services, as defined by Humana, to covered persons, including covered prescriptions or refills delivered to your home. Non-participating provider means a hospital, qualified treatment facility, qualified practitioner or any other health services provider who has not entered into an agreement with Humana to provide participating provider services or has not been designated by Humana as a participating provider. OOff-evidence drug indications mean indications for which there is a lack of sufficient evidence for safety and/or efficacy for a particular medication. Off-label drug indications mean prescribing of an FDA-approved medication for a use or at a dose that is not included in the product indications or labeling. This term specifically refers to drugs or dosages used for diagnoses that are not approved by the FDA and may or may not have adequate medical evidence supporting safety and efficacy. Off-label prescribing of traditional drugs is a common clinical practice and many off-label uses are effective, well documented in peer reviewed literature and widely employed as standard of care treatments. Orphan drug means a drug or biological used for the diagnosis, treatment, or prevention of rare diseases or conditions, which:
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Independent Review Organization (IRO means an entity that performs independent external review of Adverse Benefits Determinations and Final Internal Adverse Benefits Determinations under the external review procedures set forth in Section 6.4.3.
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Independent Review Organization (IRO means an entity that is appointed by the superintendent to conduct independent external reviews of adverse determinations and final adverse determinations pursuant to this rule; and which renders an independent and impartial decision.
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Related to Independent Review Organization (IRO

  • Independent review organization means an entity that is accredited to conduct independent external reviews of adverse benefit determinations.

  • Review organization means a disability insurer regulated

  • Utilization review organization means an entity that conducts utilization review, other than a health carrier performing a review for its own health benefit plans.

  • independent review committee means the independent review committee of the investment fund established under National Instrument 81-107 Independent Review Committee for Investment Funds;

  • Professional employer organization means an employee leasing

  • Managed Care Organization (MCO) means a contracted health delivery system providing capitated or prepaid health services, also known as a Prepaid Health Plan (PHP). An MCO is responsible for providing, arranging, and making reimbursement arrangements for covered services as governed by state and federal law. An MCO may be a Chemical Dependency Organization (CDO), Dental Care Organization (DCO), Mental Health Organization (MHO), or Physician Care Organization (PCO).

  • Managed care organization means an entity that (1) is under contract with the department to provide services to Medicaid recipients and (2) meets the definition of “health maintenance organization” as defined in Iowa Code section 514B.1.

  • Independent educational evaluation means an evaluation conducted by a qualified examiner who is not employed by the public agency responsible for the education of the child in question.

  • Independent Verification means that an evaluation is undertaken and reported by an individual or body whose organisation, systems and procedures conform to ISO Guide 65:1996 (EN 45011:1998) General requirements for bodies operating product certification systems (as amended form time to time) or equivalent, and who is accredited to audit against forest management standards by a body whose organisation, systems and procedures conform to ISO 17011: 2004 General Requirements for Providing Assessment and Accreditation of Conformity Assessment Bodies (as amended from time to time) or equivalent.

  • Designated chemical dependency specialist means a person

  • Independent Evaluator A person empowered, pursuant to Section 23.5 (Failure to Reach Agreement) and Section 23.10 (Dispute) of this Agreement, to resolve disputes due to failure of the Parties to agree on a Performance Standards Revision Document.

  • Evaluation Team means the team appointed by the City; “Information Meeting” has the meaning set out in section 2.2;

  • Supervisory Review means ongoing clinical case reviews in accordance with procedures developed by ADMINISTRATOR, to determine the appropriateness of Diagnosis and treatment and to monitor compliance to the minimum ADMINISTRATOR and Medi-Cal charting standards. Supervisory review is conducted by the program/clinic director or designee.

  • Health care organization ’ means any person or en-

  • Non-Participating Certified Clinical Nurse Specialist means a Certified Clinical Nurse Specialist who does not have a written agreement with the Claim Administrator or another Blue Cross and/or Blue Shield Plan to provide services to you at the time services are rendered.

  • Independent physician means a physician who is chosen by the resident of the assisted living facility and who has no financial interest in the assisted living facility, directly or indirectly, as an owner, officer, or employee or as an independent contractor with the residence.

  • Stewardship organization means an organization, association, or

  • Employee organization means any organization, union, or

  • Non-Participating Clinical Professional Counselor means a Clinical Professional Counselor who does not have a written agreement with the Claim Administrator or another Blue Cross and/or Blue Shield Plan to provide services to you at the time services are rendered.

  • Independent provider means a self-employed person who provides services for which he or she must be certified in accordance with rule 5123:2-2-01 of the Administrative Code and does not employ, either directly or through contract, anyone else to provide the services.

  • Independent testing laboratory means an independent organization, accepted by the Contracting Officer, engaged to perform specific inspections or tests of the work, either at the site or elsewhere, and report the results of these inspections or tests.

  • Member organization means any individual, corporation, limited liability company, partnership, or association that belongs to an association.

  • Architectural Review Committee or “ARC” shall mean the architectural review committee established by the Organization to review plans submitted to the Organization for architectural review.

  • Drug utilization review means an evaluation of a prescription drug order and patient records for

  • Provider Organization means a group practice, facility, or organization that is:

  • Participating Certified Clinical Nurse Specialist means a Certified Clinical Nurse Specialist who has a written agreement with the Claim Administrator or another Blue Cross and/or Blue Shield Plan to provide services to you at the time services are rendered.