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:	________
________
________