Do We Need to Change Our Accreditation When We Add a New Line of Review Work?
Reviewed October 2026
Check the new work against your accreditation documents and against each state's own certification or approval rules, since in IHS's reading a state that lists IROs by type of service may require its own separate approval for a new type of review, separate from your accreditation.
Accreditation comes from a private accrediting organization; in Washington and Idaho, the state insurance regulator's certification or approval governs whether you can take cases assigned under that state's external-review process; in IHS's reading, do not accept a contract for the new work until coverage is confirmed. Start with a written description of the added work. 45 CFR 147.136 requires an accredited IRO but does not say when added review work calls for a change in accreditation. The minimum standards in 45 CFR 147.136 for a state external-review process require the state to approve only accredited IROs and to keep a list of approved IROs qualified for the nature of the health care service under review. In Washington, for example, a certified IRO must report any change to the information in its certification application.
In IHS's reading, the contract's terms and the rules of each state the cases come from decide whether you can perform the work, and an accreditation certificate settles neither. Check your accreditation agreement and the standards edition that applies to your organization for any terms on adding scope.
For the federal referral process, the rule requires accreditation by URAC or a similar nationally recognized accrediting organization, while a state process must approve IROs itself. In Washington, for example, current accreditation is one requirement for certification alongside a separate application to the commissioner and proof of full-range case capacity. In Idaho, for example, the statute requires accreditation by a nationally recognized private accrediting entity whose standards the director has found equivalent, a separate application to the director, and termination of approval if accreditation is lost (Idaho Code 41-5911). The Department of Insurance's published application instructions name URAC and ask for a copy of URAC accreditation, so an IRO holding a different accreditation should confirm in writing with the Department that it will be accepted before relying on it.
In the written description of the added work, identify the clinical specialty, jurisdiction, benefit dispute, and whether the assignment is an internal review or an external appeal.
What exactly are we adding to the review service?
In IHS's reading, a new specialty calls for at least a panel and case-assignment test, while a new state, or a new type of review in a state that lists IROs by type of service, can require its own separate approval. Define the new assignment by the decision the reviewer will make, not just its specialty name.
For federal external review, 29 CFR 2590.715-2719(d)(1) includes medical-judgment determinations, specified surprise-billing and cost-sharing disputes, and rescissions. Eligibility failures under plan terms are excluded.
Which external-review process governs the new work?
Identify the applicable state or federal process before selecting an accreditation scope. Under 29 CFR 2590.715-2719(d), covered plans and issuers without an applicable state process must provide federal external review, subject to the rule's exceptions. CMS also distinguishes private accredited-IRO contracting from the HHS-administered federal route.
How do we match the accreditation program and edition?
Match the proposed work against the organization's accreditation documents and applicable standards edition.
In IHS's reading, compare the certificate's scope, accreditation agreement, standards applicability language, and customer specification side by side.
The federal rule does not list the other accrediting organizations it would treat as similar. If your accreditation comes from a body other than the one the rule names, confirm in writing that the customer, and any state where you seek certification, accepts that accreditation for the added work.
Does entering another state change more than accreditation?
Yes: Washington illustrates how state certification can add a broader operating obligation: a separate application and capacity for the state's full case range, beyond accreditation.
In IHS's reading, a narrow specialty panel therefore does not, by itself, demonstrate readiness for Washington certification. Compare the whole state case range with your operating capacity before adding Washington to the offered service. This example establishes no other state's requirements.
What has to change in the reviewer panel?
The panel needs the expertise and availability required by the added assignments. Washington requires enough qualified reviewers to cover its case range and meet expedited timelines. Its assignment rules call for clinical peers with relevant expertise and require a contract specialist when contract-interpretation issues arise.
In IHS's reading, test an assignment through the panel before describing the specialty as available. Check the proposed reviewer's qualifications against the actual rule, then identify an eligible replacement if that reviewer has a conflict or cannot meet the deadline.
Which policies and conflict controls need revision?
Revise the policies affected by the new route and test conflicts at both organizational and reviewer levels. Federal referral rules require the plan or issuer to select among at least three contracted IROs through rotation or another independent, unbiased method, and bar the IRO from incentives tied to supporting denials. Federal IRO contracts also provide for legal experts where appropriate and fresh review of the claim.
Washington requires organizational-affiliation disclosures at application and material changes, immediate rejection of a commissioner-referred case that would create an organizational conflict, and reviewers free of actual or potential conflicts in assigned cases. Its conflict waiver has specific conditions; it is not blanket permission. Washington also requires training, quality assurance, and case documentation retained for at least six years.
When is the expansion ready to offer?
IHS can check readiness with you by mapping requirements, drafting revisions for your clinicians and leadership to approve, and conducting a mock review; a team that can complete the comparison below and have someone outside the project check it does not need IHS for this step. In IHS's reading, offer the added scope when coverage is confirmed and the operating evidence supports it. Before accepting a contract, get in writing from the customer the review process, case types and states it covers, then check each one against your accreditation documents and each state's certification or approval rules; in Washington, for example, accepting commissioner referrals without certification is grounds for the commissioner to act against the organization. Keep a short decision record showing the proposed service, governing sources, applicable edition, and remaining conditions.
Counsel adds legal analysis where jurisdiction or contract meaning remains disputed. IHS drafts; the client submits and handles all communications with accreditors, regulators, and payers.
What this is NOT
This is not an accreditation decision or a recommendation to choose a particular accreditor.
This is not legal advice. Counsel should resolve disputed legal applicability and contract interpretation.
This is not a complete state survey or a statement of any accreditor's current program editions. Washington is the worked example. Internal review and other review services need their own scope analysis.
Frequently asked questions
Is accreditation enough to be certified as an IRO in Washington?
No. WAC 284-43A-020 requires an application to the commissioner and a current accreditation from a nationally recognized private accrediting organization acceptable to HHS or DOL for the federal external review process. It also requires the ability to handle a full range of Washington cases, including contract provisions. In IHS's reading, an accreditation certificate is therefore one input to a state expansion decision, not the whole of it.
Can a specialist subcontractor solve the Washington capacity question?
Only as part of a compliant arrangement. Washington permits specialized subcontracting, but the certified IRO remains responsible for every review meeting the chapter's requirements. In IHS's reading, document that oversight before relying on the subcontractor.
About the author
Thomas G. Goddard, JD, PhD, has been Chief Executive Officer of Integral Healthcare Solutions since 2002. He served as Chief Operating Officer and General Counsel of URAC from 1998 to 2000.
Integral Healthcare Solutions: accreditation consulting, compliance services, and program development.
Sources
Internal claims and appeals and external review processes, 45 CFR 147.136, HHS, eCFR: https://www.ecfr.gov/current/title-45/subtitle-A/subchapter-B/part-147/section-147.136
Internal claims and appeals and external review processes, 29 CFR 2590.715-2719, Department of Labor, eCFR: https://www.ecfr.gov/current/title-29/subtitle-B/chapter-XXV/subchapter-L/part-2590/subpart-C/section-2590.715-2719
HHS-Administered Federal External Review Process for Health Insurance Coverage, CMS: https://www.cms.gov/cciio/programs-and-initiatives/consumer-support-and-information/csg-ext-appeals-facts
Independent Review Organizations, Chapter 284-43A WAC, Washington Office of the Insurance Commissioner, Washington State Legislature: https://app.leg.wa.gov/WAC/default.aspx?cite=284-43A&full=true
Independent Review Organization, Idaho Department of Insurance: https://doi.idaho.gov/industry/licensing-services/license-types/independent-review-organization/
Idaho Code 41-5911, Idaho Legislature: https://legislature.idaho.gov/statutesrules/idstat/Title41/T41CH59/SECT41-5911/
Last updated: October 31, 2026. Sources were retrieved on October 30 and again on October 31, 2026 for the sentences revised that day. Requirements change and must be verified with the issuing body.