WAC 284-212-054. Form for reporting independent third-party review decisions

The following form must be used by issuers to annually report independent third-party review appeal decisions concerning changes made by issuers for supplemental long-term care policyholders under RCW 48.212.090 (2). INDEPENDENT THIRD-PARTY REVIEW APPEALS REPORTING FORM FOR SUPPLEMENTAL LONG-TERM CARE INSURANCE POLICYHOLDERS IN THE STATE OF WASHINGTON FOR THE REPORTING YEAR 20[ ] Company Name: Address: Phone Number: Independent Third-Party Reviewer Name: Address: Phone Number: Website Address: Due: March 1, annually Instructions: The purpose of this form is to report all independent third-party review appeal requests and decisions. Please furnish one form per each independent third-party reviewer decision. Policy Form # Policy and Certificate # Name of Insured Date of Policy Issuance Date/s Issuer Determination Date/s Request for Independent Review Date/s of Independent Review Decision Policy Form # Policy and Certificate # Name of Insured Date of Policy Issuance Date/s Issuer Determination Date/s Request for Independent Review Date/s of Independent Review Decision Detailed reason for initial issuer determination and independent third-party reviewer decision: Signature Name and Title (please type) Date