DEPARTMENT OF LABOR AND REGULATION

DIVISION OF INSURANCE

MODEL HEALTH CARRIER EXTERNAL REVIEW ANNUAL REPORT FORM

Chapter 20:06:53

APPENDIX D

SEE: § 20:06:53:65

Appendix D - Model Health Carrier External Review Annual Report Form

Health Carrier External Review Division of Insurance Annual Report Form

External Review Annual Summary for 20_____

Due on ___________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 the South Dakota Division

of Insurance 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:

_______

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