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054.00.76 Appendix D. Model Health Carrier External Review Annual Report Form

AR ADC 054.00.76 Appendix DArkansas Administrative Code

West's Arkansas Administrative Code
Title 054. Insurance Department
Division 00.
Rule 76. Arkansas External Review Regulation
Ark. Admin. Code 054.00.76 Appendix D
054.00.76 Appendix D. Model Health Carrier External Review Annual Report Form
Currentness
Arkansas Insurance Department
Health Carrier External Review Annual Report Form
External Review Annual Summary for 20
_____.
Due on [insert date] for previous calendar year.
Each health carrier shall submit an annual report with information in the aggregate by State and by type of health benefit plan.
1. Health carrier name:
___________________________________
Filing Date:
____________________
2. Health carrier address:
______________________________________________________________________
City, State, ZIP:
______________________________________________________________________
3. Health carrier Web site:
___________________________________
4. Name, email address, phone and fax number of the person completing this form:
______________________________________________________________________
______________________________________________________________________
5. Total number of external review requests received from [insert state insurance department name] during the reporting period:
____________
6. From the total number of external review requests provided in Question 5, the number of requests determined eligible for a full external review:
____________
_____________________________________________

Credits

Adopted Jan. 6, 2012.
Current with amendments received through February 15, 2024. Some sections may be more current, see credit for details.
Ark. Admin. Code 054.00.76 Appendix D, AR ADC 054.00.76 Appendix D
End of Document