Independent review organization (IRO) An independent review organization (IRO) conducts the independent (or external) review of an appeal. An IRO is a group of medical and benefit experts certified by the Washington State Department of Health and not related to the plan, Regence BlueShield, WSRxS, or HCA. An IRO is intended to provide unbiased, independent clinical and benefit expertise, as well as evidence-based decision making while ensuring confidentiality. The IRO reviews your appeal to determine if the plan’s decision is consistent with state law and the applicable COC. The plan pays the IRO’s charges. See “External review (independent review)” on page 131. Intensive Outpatient Program Intensive Outpatient Program (IOP) is an outpatient program that is licensed as a facility or agency by the appropriate state agency and is provided under the supervision of a psychiatrist or psychiatric extender. IOP is intended to provide treatment on an outpatient basis, does not include boarding or housing, and is intended to provide treatment interventions in a structured setting, with patients returning to their home environments each day. IOP is a minimum of three hours per day, three days per week. Limited benefit TIP: This definition applies only to those benefits in which it is used in this COC. Other benefits have additional limits related to medical necessity or preauthorization of services (see the “Limits on plan coverage” section). A limited benefit is a benefit that is limited to a certain number of visits or a maximum dollar amount. The limit applies to these benefits even if the provider prescribes additional visits and even if the visits are medically necessary. For benefits limited to a certain number of visits, any visits that are applied to your medical deductible also count against your annual visit or dollar limit. In addition, visits that are paid by another health plan that is primary apply to the plan limit. For example, if your primary plan applies your first 12 chiropractor sessions to your medical deductible, you may receive coverage for 12 more sessions in that calendar year, for a total of 24 visits (the visit maximum for chiropractic services). For benefits limited to a certain dollar amount (e.g., hearing aids), you pay all charges billed to you above the maximum dollar amount. Any amounts billed above the maximum dollar limit do not apply to your out-of-pocket limit. These limits apply per member. Services are counted against a limited benefit according to the type of service, not the provider type. When a provider practicing within the scope of their license provides services coded under a limited benefit (e.g., spinal manipulation or physical therapy), those services will be counted against the benefit regardless of the provider type. In addition, if more than one type of limited benefit service is provided during a single visit, the services will count against all the limited benefits. For example, if both manipulation and physical therapy codes are billed for a visit, that visit will count against both the spinal and extremity manipulation and physical therapy benefit limits. Maintenance care Maintenance care is a health intervention after the member has reached maximum rehabilitation potential or functional level and has shown no significant improvement for one to two weeks, and instruction in the maintenance program has been completed. 182 2024 UMP Select (PEBB) Certificate of Coverage