23 CAR pt. 117, Appendix D
23 CAR pt. 117, Appendix D. Model Health Carrier External Review Annual Report Form
Length: 142 wordsOfficial source
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Appendix D
Model Health Carrier External Review Annual Report Form
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:
___________
_____________________________________________