External Independent Review Organization Registration Guidelines - Application and Registered EIRO Listing
What are External Independent Review Organizations?
An External Independent Review Organizations (EIRO) is an entity that conducts independent external reviews of adverse determinations and final adverse determinations involving the medical necessity, appropriateness, health care setting, level of care or effectiveness of a requested service. Not included in this definition are:
- a policy or certificate that provides coverage only for a specified disease, specified accident or accident-only coverage, credit, dental, disability income, hospital indemnity, long-term care insurance as defined by Article XIXA of the Illinois Insurance Code;
- vision care, or any other limited supplemental benefit;
- a Medicare supplement policy of insurance as defined by the Director by regulation;
- coverage under a plan through Medicare, Medicaid, or the federal employees health benefits program;
- any coverage issued under Chapter 55 of Title 10, U.S. Code (Armed forces - Medical and Dental Care) and any coverage issued as supplement to that coverage;
- any coverage issued as supplemental to liability insurance, workers' compensation, or similar insurance; and
- automobile medical-payment insurance or any insurance under which benefits are payable with or without regard to fault, whether written on a group blanket or individual basis.
When must External Independent Review Organizations Register?
Beginning July 1, 2010, all EIROs must register with the Director of Insurance. In order to be eligible for approval by the Director, an EIRO must secure and maintain a current certificate of accreditation by the American Accreditation Healthcare Commission (URAC) under applicable standards for Independent Review Organizations. Registration of Illinois EIROs is effective for a period of two years and must be renewed biennial. Each EIRO registration must contain a completed Application for Registration of an Independent Review Organization (Section 5430 Appendix D) and External Independent Review Organization Officers and Directors Biographical Affidavit (Section 5430 Appendix F).
Who must Register as an External Independent Review Organization?
Any entity that conducts independent external reviews of adverse determinations and final adverse determinations on behalf of an entity that is subject to the insurance laws and regulations of this State, or subject to the jurisdiction of the Director, that contracts or offers to contract to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services, including a sickness and accident insurance company, a health maintenance organization, or any other entity providing a plan of health insurance, health benefits, or health care services; including Limited Health Service Organizations (LHSO) and Voluntary Health Service Plans.
What is the registration fee for an Illinois External Independent Review Organization?
A registration fee of $1,000 must be submitted with each application or renewal thereof
All checks or money orders must be made payable to the Director of Insurance, State of Illinois.
Mail Completed Applications to:
Illinois Department of Insurance
Managed Care Compliance Unit
320 West Washington Street
Springfield, Il 62767-0001
ANY MATERIAL CHANGES IN YOUR IRO APPLICATION MUST BE FILED WITH THE DIRECTOR WITHIN 30 DAYS OF THE CHANGE.
If you have questions, please contact the Illinois Department of Insurance at 217-557-6953 or DOI.Managed.Care@illinois.gov