Appendix D – Health Carrier External Review Annual Report Form

Appendix D – Health Carrier External Review Annual Report Form Mississippi 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 Mississippi Insurance Department 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:___________