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. 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:				_____