State of Indiana - HMS Permedion



Permedion

Independent Medical Review

Disclosure Requirements

Upon agreement to accept a case, each reviewer agrees to the following requirements. If any requirement is not fulfilled, the reviewer agrees to provide immediate notification of changes or sanctions on licenses to Permedion.

1. The medical review professional conducting the external review may not have a material professional, familial, financial, or other affiliation with any of the following:

1) Health plan or hospital

2) Any officer, director, or management employee of the health plan or hospital.

3) The physician or the physician's medical group that is proposing the service.

4) Enrollee(s) and/or patient(s).

5) Facility at which the service would be provided.

6) Development or manufacture of the principle drug, device, procedure, or other therapy that is proposed by the treating physician.

However, the medical review professional may have an affiliation under which the medical review professional provides health care services to enrollees of the health maintenance organization and may have an affiliation that is limited to staff privileges at the health facility if the affiliation is disclosed.

2. The medical review professional may not accept compensation for independent review activities that is dependent in any way on the specific outcome of the case.

3. The medical review professional may not have involvement with the case prior to its referral to independent review.

4. Board certification is current.

5. Current license with no history of sanctions and/or disciplinary actions.

6. Actively practicing.

Please disclose any known issues below:

________________________________________________________________________________________________________________________________________________________

Your signature is also a guarantee that upon acceptance of each assigned case review, any issue with compliance will be immediately disclosed to a Permedion representative.

___________________________________ _______________________

Signature Date

This document will be kept on file at Permedion.

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