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054.00.76 Appendix C. Independent Review Organization External Review Annual Report Form Arkans...

AR ADC 054.00.76 Appendix CArkansas 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 C
054.00.76 Appendix C. Independent Review Organization External Review Annual Report Form Arkansas Insurance Department
Currentness
Independent Review Organization External Review Annual Report Form
External Review Annual Summary for 20
______.
Due on [insert date] for previous calendar year.
Each independent review organization (IRO) shall submit an annual report with information for each health carrier in the aggregate on external reviews performed in Arkansas only.
1. IRO name:
___________________________________
Filing date:
___________________
2. IRO license/certification no:
______________________
3. IRO address:
______________________________________________________________________
City, State, ZIP:
______________________________________________________________________
4. IRO Web site:
________________________________________
5. Name, email address, phone and fax number of the person completing this form:
______________________________________________________________________
______________________________________________________________________
6. Name and title of the person responsible for regulatory compliance and quality of external reviews:
Name:
______________________________
Title:
________________________________________
7. Total number of requests for external review received from [insert state insurance department name] during the
reporting period:
_______
8. Number of standard external reviews:
________
9. Average number of days IRO required to reach a final decision in standard reviews:
____________
10. Number of expedited reviews completed to a final decision:
____________
11. Average number of days IRO required to reach a final decision in expedited reviews:
_______________
12. Number of medical necessity reviews decided in favor of the health carrier:
____________
Briefly list procedures denied:
____________________________________________________________
13. Number of medical necessity reviews decided in favor of the covered person:
____________
Briefly list procedures approved:
_______________________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________
14. Number of experimental/investigational reviews decided in favor of the health carrier:
__________
Briefly list procedures denied:
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
15. Number of experimental/investigational reviews decided in favor of the covered person:
__________
Briefly list procedures approved:
_______________________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________
16. Number of reviews terminated as the result of a reconsideration by the health carrier:
____________
17. Number of reviews terminated by the covered person:
_____________
18. Number of reviews declined due to possible conflict with:
Health carrier
__________
Covered person
______________
Health care provider
______________
Describe possible conflicts(s) of interest:
_______________________________________________________
19. Number of reviews declined due to other reasons not reflected in #18 above:
___________________

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 C, AR ADC 054.00.76 Appendix C
End of Document