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054.00.76-15. External Review Reporting Requirements

AR ADC 054.00.76-15Arkansas Administrative Code

West's Arkansas Administrative Code
Title 054. Insurance Department
Division 00.
Rule 76. Arkansas External Review Regulation
Ark. Admin. Code 054.00.76-15
054.00.76-15. External Review Reporting Requirements
Currentness
A.(1) An independent review organization assigned pursuant to Section (8), Section (9) or Section (10) of this Rule to conduct an external review shall maintain written records in the aggregate by State and by health carrier on all requests for external review for which it conducted an external review during a calendar year and, upon request, submit a report to the Commissioner, as required under (A)(2) of this Section.
(2) Each independent review organization required to maintain written records on all requests for external review pursuant to (A)(1) of this Section for which it was assigned to conduct an external review shall submit to the commissioner, upon request, a report in the format specified by the commissioner.
(3) The report shall include in the aggregate by State, and for each health carrier:
(a) The total number of requests for external review;
(b) The number of requests for external review resolved and, of those resolved, the number resolved upholding the adverse determination or final adverse determination and the number resolved reversing the adverse determination or final adverse determination;
(c) The average length of time for resolution;
(d) A summary of the types of coverages or cases for which an external review was sought, as provided in the format required by the Commissioner;
(e) The number of external reviews pursuant to Section (8)(G) of this Rule that were terminated as the result of a reconsideration by the health carrier of its adverse determination or final adverse determination after the receipt of additional information from the covered person or the covered person's authorized representative; and
(f) Any other information the Commissioner may request or require.
(4) The independent review organization shall retain the written records required pursuant to this subsection for at least three (3) years.
B.(1) Each health carrier shall maintain written records in the aggregate, by State and for each type of health benefit plan offered by the health carrier on all requests for external review that the health carrier receives notice of from the Commissioner pursuant to this Rule.
(2) Each health carrier required to maintain written records on all requests for external review pursuant to paragraph (1) shall submit to the Commissioner, upon request, a report in the format specified by the Commissioner.
(3) The report shall include in the aggregate, by State, and by type of health benefit plan:
(a) The total number of requests for external review;
(b) From the total number of requests for external review reported under (B)(3)(a) of this Section, the number of requests determined eligible for a full external review; and
(c) Any other information the Commissioner may request or require.
(4) The health carrier shall retain the written records required pursuant to this subsection for at least six (6) years.

Credits

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