ARSD 20:06:53:0C – Independent Review Organization External Review Annual Report Form.

DEPARTMENT OF LABOR AND REGULATION

DIVISION OF INSURANCE

INDEPENDENT REVIEW ORGANIZATION EXTERNAL REVIEW ANNUAL

REPORT FORM

Chapter 20:06:53

APPENDIX C

See: § 20:06:53:64

Appendix C - Independent Review Organization External Review Annual Report Form

South Dakota Division of Insurance

Independent Review Organization External Review Annual Report Form

External Review Annual Summary for 20________

Due on [________] 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 South Dakota 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 South Dakota Division of

Insurance 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 Question 18:

Source: 37 SDR 48, effective September 22, 2010.