Physician Reviewer Manual | Updated PR Job Description

The PR Manual serves not only as an orientation document to new peer reviewers, but as a resource and guide to both novice and experienced PRs.  Particularly useful is the General Guidelines – Dos and Don’ts of Peer Review (Pages 14-15). 

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Other highly informative topics include approach for review, types of reviews, client reports, fair hearings, and tips on health plan coverage review for experimental/investigational or medical necessity.
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The PR Job Description (Page 23) was recently updated with clarifications to PR experience, the removal of active admitting privileges, and a requirement that all review activity be performed within the United States.   

• Experience – Physicians must be five years post medical school graduation with completion of residency program and fellowship, if applicable. Case-by-case consideration will be given to physicians in a specialty/sub-specialty fellowship to have met experience requirements e.g., able to conduct peer review for internal medicine case while pursuing nephrology specialty if all other requirements are met.   Advanced practice practitioners must be five years post certification to become a PR.  Require broad clinical background with at least two years prior experience managing the medical condition, procedure, treatment, or issue under review and/or in the specialty area required. 

 
PRs for health plan/external reviews must have five years of full-time equivalent experience providing direct clinical care to patients. Through clinical experience in the past three years, these reviewers must be experts in the treatment of the covered person's condition and knowledgeable about the recommended or requested health care service or treatment. 

• Removal of Active Admitting Privileges – The requirement for active admitting privileges in at least one hospital has been eliminated. However, PRs must be engaged in active medical practice (teaching medicine and/or practicing direct patient care for at least eight hours per month) and must demonstrate familiarity with the current body of knowledge and medical practice through affiliation with a university, such as teaching or research; or by obtaining CMEs necessary to maintain licensure.

 

• Prohibit Review Outside of the US - All review activity must be performed within the United States.  Due to privacy and security concerns, PRs are prohibited from taking information outside of the United States, and from processing, transmitting, or sharing information from outside of the United States.

The PR job description is part of the Subcontract and BAA for Peer Reviewers and is provided as an attachment to the PR Manual.  This information is always accessible on CIMRO’s website for reference.