CIMRO - EXTERNAL INDEPENDENT REVIEW

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External Independent Review Process

The Illinois Health Carrier External Review Act became effective on July 1, 2010. This Act guarantees all insured citizens of Illinois the right to an independent external review of denied health insurance claims. This external review must be conducted by a nationally accredited External Independent Review Organization (EIRO) approved by the Illinois Department of Insurance (DOI).

CIMRO was certified as an EIRO by the Illinois DOI on June 30, 2010. We can immediately assist you in meeting the DOI requirements to be compliant with the External Review Act.

To request our IRO Agreement for Review Services and to discuss our competitive pricing structure, call Jennifer Kirkland, RN, BS, CPHQ, Project Manager at 800.635.9407, ext. 4202, or contact via email at jkirkland@cimro.com.

Once a contract is in place, following are the steps to request an external independent review and an overview of the review process:

Call CIMRO at 800.635.9407 and provide the following information:
- Health Plan name
- Patient’s first and last name
- Whether review is Standard or Expedited
- Peer review specialty needed
- Your contact information
Forward all necessary information required to review the case to CIMRO’s office, including all documentation related to prior appeals. Identify if the request is a STANDARD or an EXPEDITED review on our Request for Review form.
- The standard EIRO review time frame is five (5) business days following receipt of the necessary information.
- Expedited reviews will be conducted within two (2) business days for cases where the covered person has a medical condition where the time frame for review would seriously jeopardize the person’s life or health, or ability to regain maximum function, or if the person has not been discharged from a facility and the case involves an admission or continued stay denial.
Within one (1) day of receipt, CIMRO staff will conduct a cursory review to determine such things as whether sufficient information is provided for a determination, the type of case (medical necessity vs. experimental/investigational), whether the case merits standard or expedited review, and whether an organizational conflict of interest (COI) exists.
- If an organizational COI is identified, CIMRO will return the case to you without reviewing.
If additional information is needed, CIMRO will contact you, and you must provide the requested information within five (5) business days for standard reviews.
- If the necessary information is not provided within that time frame, CIMRO may terminate the external review and determine to reverse the adverse decision.
- Should this occur, you and the covered person/authorized representative will be notified of the determination in writing within one (1) business day following the decision.
If the covered person/authorized representative provides additional information for consideration directly to CIMRO, CIMRO will forward the documents to you for reconsideration.
- The external review will only be terminated if you decide to reverse the adverse determination.
- You must provide written notice of reversal to CIMRO and the covered person/authorized representative within one (1) business day after making the decision.
For standard external reviews, CIMRO will provide written notice of the review determination to you and the covered person/authorized representative within five (5) business days of receipt of all necessary information.
For expedited external reviews, CIMRO will provide verbal notice of the review determination to you and the covered person/authorized representative within two (2) business days of receipt of all necessary information.
- CIMRO will provide written confirmation of the review determination to you and the covered person/authorized representative within 48 hours following the date of the verbal notice.