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  • INDEPENDENT REVIEW ORGANIZATION (IRO)

    APPLICATION FORM
  • General Information

    If more room is needed, please attach additional sheets
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  • 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:
  • 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.

  • 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.

  • Please print and upload the certification page and affidavit page before submitting the application.
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