Appendix C – Independent Review Organization External Review Annual

Appendix C – Independent Review Organization External Review Annual Report Form Mississippi 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 Mississippi only. 1. IRO name:_________________________________________ Filing date:__________________ 2. IRO license/certification no: _____________________ 3. IRO address:______________________________________________________________________________ City, State,ZIP:___________________________________________________________________________ IRO Web site:_________________________________________________________________________________ 4. Name, email address, phone and fax number of the person completing this form: ______________________________________________________________________________ ______________________________________________________________________________ 5. Name and title of the person responsible for regulatory compliance and quality of external reviews: Name:______________________________________ Title:______________________________________ 6. Total number of requests for external review received from Mississippi Insurance Department during the reporting period:________ 7. Number of standard external reviews:_______ 8. Average number of days IRO required to reach a final decision in standard reviews: __________ 9. Number of expedited reviews completed to a final decision:___________ 10. Average number of days IRO required to reach a final decision in expedited reviews:__________ 11. Number of medical necessity reviews decided in favor of the health carrier:___________ Briefly list procedures denied:______________________________________________________________ 12. Number of medical necessity reviews decided in favor of the covered person:___________ Briefly list procedures approved: ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ 13. Number of experimental/investigational reviews decided in favor of the health carrier:________ Briefly list procedures denied: ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ 14. Number of experimental/investigational reviews decided in favor of the covered person:________ Briefly list procedures approved: ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ 15. Number of reviews terminated as the result of a reconsideration by the health carrier:________ 16. 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:__________________