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INDEPENDENT REVIEW ORGANIZATION (IRO)
APPLICATION FORM
General Information
If more room is needed, please attach additional sheets
Type of Application:*
- Original
- Renewal
- Update/Change to Original Application
Type of Entity:*
- Corporation
- Partnership
- Limited Liability Company
- Other
If other, please explain:

Primary Office Address (Do Not Use P.O. Box):*
Street Address Address Line 2 City State ZIP Code
Mailing Address (if different):
Street Address Address Line 2 City State ZIP Code

Address:*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email:*
Website:

Telephone Number:*
Toll-Free Number:
Fax Number:
List of all the states in which applicant is approved to conduct external review(s):*
Hold the ctrl button to select multiple states.

Identify all accreditations held by the Applicant:*
Has the applicant ever had an application denied by any state regulatory authority?*
- Yes
- No
Explain, if "Yes"*
Has the applicant ever been the subject of regulatory action?*
- Yes
- No
Explain, if "Yes"*
Has the applicant ever lost accreditation to perform independent reviews?*
- Yes
- No
Explain, if "Yes"*

Organizational Documents and Relationships
Does the applicant own or control, or is it owned or controlled (in whole or in part) by, or does it have a contractual relationship with:
(a) an insurer*
- Yes
- No
Explain, if "Yes"*
(b) health benefit plan*
- Yes
- No
Explain, if "Yes"*

(c) trade association*
- Yes
- No
Explain, if "Yes"*
(d) health care provider*
- Yes
- No
Explain, if "Yes"*
Do any clinical reviewers employed by or contracted with the applicant have a history of being the subject of disciplinary action?*
- Yes
- No
Explain, if “Yes”*

Provide a chart showing the internal structure of the Applicant’s management and administrative staff.

Provide a detailed description of the procedures used by the applicant to ensure that the identity, financial information, and medical information of a claimant is not disclosed.
Provide a description of the applicant’s written policies and procedures that govern all aspects of both the standard independent review and the expedited independent review process, including the procedures to ensure:
- that an independent review is conducted within the specified timeframe and that a required notice is provided in a timely matter;
- the selection of a qualified and impartial clinical reviewer to conduct the independent review and suitable matching of the review to a specific case; and
- that any individual employed by or under contract with the IRO adheres to all requirements

CERTIFICATION
*
Please print your name if you are acting on behalf of the Applicant.
*
Please enter the name of the institution that has provided accreditation to the applicant to conduct independent external reviews.
I also state that I have read and understand the requirements for conducting external reviews for residents of New Mexico found at NMAC 13.10.17.19-23. Further, I have read the Memorandum of Understanding (MOU) between the NM Office of Superintendent of Insurance and IROs, and I am willing to execute the MOU and comply with the conditions set forth therein.

I have fully and truthfully completed this form to the best of my knowledge, information, and belief.

I have the authority and capacity to execute this certification on behalf of the Applicant.

I acknowledge that the NM Superintendent of Insurance has the sole discretion to add or remove the name of any IRO from the list of approved IROs, and the Superintendent’s decision to not approve any organization or to remove any organization’s approval is not subject to administrative appeal or judicial review.

Applicant*
Signature*
Print or type full legal name*
Title*
Please print and upload the certification page and affidavit page before submitting the application.
File*
Drop files here or
Maximum allowed size of file is 2048MB
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INDEPENDENT REVIEW ORGANIZATION (IRO)