OAR 836-053-1345: Quality Assurance Mechanisms

(1) An independent review organization must have a quality assurance program that ensures the timeliness, quality of review and communication of determinations to enrollees and insurers. The program must also ensure the qualifications, impartiality and freedom from conflict of interest of the organization, its staff and medical reviewers. The quality of review of an independent review organization includes the use of appropriate methods to match the case, confidentiality and systematic evaluation of complaints for patterns or trends. (2) A quality assurance program must include a written plan addressing its scope and objectives; program organization, monitoring and oversight mechanisms; and evaluation and organizational improvement of independent review organization activities. Organizational improvement must include the implementation of action plans to improve or correct identified problems, and communication of the results of action plans to staff and medical reviewers. (3) An independent review organization shall record complaints in a log. The log shall include for each complaint the nature of the complaint and how it was resolved. Upon request, the independent review organization shall provide the log and complaints to the director for review.