Step 1 of 13 7% INDEPENDENT REVIEW ORGANIZATION (IRO)APPLICATION FORM General InformationIf more room is needed, please attach additional sheetsType of Application:* Original Renewal Update/Change to Original Application Type of Entity:* Corporation Partnership Limited Liability Company Other If other, please explain: Name of Applicant:*FEIN:*DBA Name: Primary Office Address (Do Not Use P.O. Box):* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Mailing Address (if different): Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Office Telephone Number:*Fax Number:Primary Contact Person:* First Last Address:* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email:* Telephone Number:*Fax Number:Primary Contact for Complaints:* First Last Address:* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands 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):*AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificHold 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 RelationshipsDoes 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 Provide a description of the applicant’s quality assurance program. Provide a description of the policies and procedures that the applicant will follow to ensure the independence of the IRO and the clinical reviewer. CERTIFICATIONPlease print your name if you are acting on behalf of the Applicant.* 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.*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 Select files Max. file size: 2 MB. Maximum allowed size of file is 2048MB CAPTCHA