Compliance has never been as critical as it is in today’s healthcare environment. The MRIoA Compliance Program proactively tracks applicable state and federal laws and regulations, and identifies and resolves issues to ensure compliance with all state and federal requirements.

MRIoA approaches ongoing compliance developments with innovation and flexibility, both in our processes and our products as we continue to stay ahead of legislative changes and new regulations.

New State Regulatory Requirements for Health and Pharmacy: Get Compliant Now — AVOID Penalties Later…

Enabled many health plans to meet regulatory requirements across 7 states with little to no disruption to their clinical operations

Georgia Health and Rx Requirements

Effective January 1, 2022

  • Includes QHPs and fully insured plans
  • If you have a prior authorization (PA) process, you will be required to post PA processes and specific PA data to your websites
  • Specialty matching required at all levels
  • Peer-to-peer (P2P) required prior issuing an adverse determination
  • Active practice required at all levels

Nebraska Rx Requirements

Effective January 1, 2022

  • Includes fully insured plans
  •  If an insurer establishes step therapy protocols, plans will need to create or adopt a step therapy exceptions process and make step therapy criteria available upon request

California Rx Requirements

Effective January 1, 2022

  • Includes fully insured plans
  • If an insurer establishes PA and/or step therapy protocols, plans will need to create or adopt a step therapy exceptions process

Texas Health and Rx Requirements

Effective September 1, 2021

  • Includes QHPs and fully insured plans
  • Adds same state, same specialty requirement for P2Ps prior to issuing an adverse determination
  • Plans must also develop a PA exemption process

Illinois Health and Rx Requirements

Effective January 1, 2022

  • Includes Medicaid, QHPs, and fully insured plans
  • Specialty matching required at all levels for prior authorizations

Illinois Behavioral Health Requirements

Effective January 1, 2023

  • Includes Medicaid, QHPs, and fully insured plans
  • Specialty matching required at all levels for behavioral health reviews
  • Criteria and guidelines used must be developed by a nonprofit association for the relevant specialty.
  • ASAM criteria must be used for SUD cases

Arkansas Rx Requirements

Effective January 1, 2022

  • Includes QHPs, HMOs, self-insured governmental or church plans, plans providing benefit to AR state and school employees and fully insured plans
  • Plans will need to create or adopt a step therapy exception process
  • Initial and Appeal TATs: 72 hrs. standard, 24 hrs. expedited

Arizona Health and Rx Requirements

Effective July 22, 2021

  • Includes fully insured plans
  • Removes the same state medical director exemption for URAC or NCQA accredited organizations. Insurers must have an Arizona licensed medical director responsible for all PA denials.

Join MRIoA Round Table Discussion to Get the Latest Updates on Continuous Regulatory Monitoring

MRIoA’S COMPREHENSIVE COMPLIANCE PROGRAM INCLUDES:

State Licensures

MRIoA is licensed to conduct utilization review in all states where required.

Corporate Policy and Procedures

Comprehensive policies and procedures incorporate all applicable state and federal legislative and regulatory requirements and guidance, accreditation standards and industry best practices, and are reviewed at least annually and updated as necessary.

Oversight

Monitoring and auditing of MRIoA employees and reviewer panel members for legal and licensing complaints monthly ensures continued compliance with state, federal, accreditation and contractual requirements.

Medical Director Licensures

MRIoA’s team of Medical Directors hold licenses in 41 states to meet same state license requirements for oversight and review.

Privacy and Security

MRIoA takes the privacy and security of your information very seriously. MRIoA’s privacy and security program incorporates the HITRUST Common Security Framework (CSF) and associated standards/regulations referenced within, including HIPAA, HITECH, and state data and privacy laws. MRIoA maintains strict access controls including privileged access, file integrity monitoring, input validation and comprehensive audit logging, and ensures confidentiality of data by using AES-256 encryption for data at rest and TLS1.2 for data in transit.

Training

All MRIoA employees and contractors receive comprehensive training upon hire and annually thereafter. Topics include but are not limited to:

  • HIPAA
  • Code of Conduct
  • Confidentiality
  • Security
  • Conflict of Interest
  • URAC
  • Fraud, Waste and Abuse

ACCREDITATIONS, CERTIFICATIONS AND MEMBERSHIPS

URAC – HUM

URAC is a non-profit independent accrediting agency that is known as a leader in promoting healthcare quality. Organizations that obtain accreditation demonstrate a commitment to quality and excellence with consistent compliance with best practices. MRIoA holds two URAC accreditations in Health Utilization Management (HUM) and Independent Review Organization (IRO).

NAIRO

NAIRO (National Association of Independent Review Organizations) is a national trade association of URAC-accredited IROs whose primary mission is to protect the integrity of the independent review process.

NCQA – UM

NCQA is a non-profit organization dedicated to improving healthcare quality. The NCQA seal is a widely recognized symbol of quality. MRIoA is NCQA accredited in Utilization Management (UM).

AICPA SOC

These reports are intended to meet the needs of a broad range of users that need detailed information and assurance about the controls at a service organization relevant to security, availability, and processing integrity of the systems the service organization uses to process users’ data and the confidentiality and privacy of the information processed by these systems. These reports can play an important role in oversight of the organization, vendor management programs, internal corporate governance and risk management processes, and regulatory oversight.

URAC – IRO

URAC’s Independent Review Organization (IRO) accreditation standards validate that third-party organizations providing medical determinations are committed to a fair and impartial peer review process for both patients and physicians.

HITRUST

HITRUST (Health Information Trust Alliance) has developed the HITRUST CSF, a certifiable framework that provides organizations with the structure, detail and clarity relating to information security tailored to the healthcare industry. HITRUST certification signifies commitment to ongoing IT security.

SIIA

The Self-Insurance Institute of America, Inc. (SIIA) is a member-based association dedicated to protecting and promoting the business interests of companies involved in the self-insurance and captive insurance industry. Members include, self-insurance entities, TPAs, Captive Managers, Excess/Stop-Loss Carriers and other industry service providers.

Best Places to Work

MRIoA earned the 2021 Top Workplaces USA award, issued by Energage. Top Workplaces USA offers national recognition for large organizations, those with more than 150 employees, and those that have operations in multiple markets. This award is in addition to our Top Workplaces Salt Lake City award that we have received every year since 2018.