23 CAR pt. 117, Appendix C. Independent Review Organization External Review Annual Report Form

11 Appendix C Independent Review Organization External Review Annual Report Form Arkansas Insurance Department 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 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: __________________