IRO FAQ's
Q. Are all health insurers and HMOs required to participate in the IRO process?
A. No. Call your plan to ask if it participates in the IRO process.
Q. How soon must I request an IRO review after my health plan denies me treatment?
A. There is no time limit to request an IRO review for treatment denials; however, you should try to request the review as soon as possible.
Q. May I request an IRO review for all treatment denials by my health plan?
A. No. The IRO process applies only when your health plan or URA ( Utilization Review Agency) decides that the health care your doctor recommends – but you haven’t received or are currently receiving – is medically unnecessary or inappropriate.
Q. What if I have an emergency? Do I have to wait for a treatment coverage decision from an IRO?
A. No. If you need emergency care, seek treatment immediately. The IRO process does not affect your right to seek emergency care.
Q. What if my insurer or HMO tells me that the IRO process is not available to me because my health plan does not cover the services in question?
A. You may file a complaint or an appeal with the insurer or HMO.
Q. Can I sue the insurance company or HMO that refuses to pay for treatment?
A. If your HMO or insurer is subject to state law, you may be able to file a medical malpractice suit against your HMO or insurer, as well as your physician. If you file notice to your HMO or insurer of the intent to file a lawsuit, your HMO or insurer may request an IRO review within 14 days of receiving notice of a potential suit regarding treatment denial. If the HMO or insurer chooses to request an IRO review, it is legally required to comply with all state IRO requirements. You should contact your attorney for additional information or advice about suits against HMOs and insurers.
Q. Do IRO’s have to maintain the confidentiality of data?
A. Yes, in conjunction with the independent review process, the IRO must preserve the confidentiality of individual medical records, personnel information, and any proprietary information provided by payors. Personal information includes your name, address, telephone number, social security number, and financial information.