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).
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.
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.
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.
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.