Illinois Administrative Code › Title 50 - INSURANCE › Part 4530 - HEALTH CARRIER EXTERNAL REVIEW › Appendix D - Independent Review Organizations - Application for Reapproving Independent Review Organizations

Current through Register Vol. 48, No. 28, July 12, 2024
INDEPENDENT REVIEW ORGANIZATION
Renewal Registration Form
[Today's Date]
Company Name:
				________________________________________________________
FEIN:
				_________________________________________________________________
Contact Person:
				_________________________________________________________
Telephone: (
				)____________________________________________________________
Email Address:
				__________________________________________________________
Street Address:
				__________________________________________________________
City, State, Zip:
				__________________________________________________________
Renewal registration for Independent Review Organization
				covering period __/__/__ through __/__/__.
Instructions for completing renewal registration:
1. Please verify all information regarding company
				name, contact person and address to be complete and accurate;
2. Submit a current copy of the applicable
				accreditation certificate from the American Accreditation Healthcare Commission
				(URAC) if applicable;
3. Submit any material changes to the information
				filed under your prior registration:
a. Verify toll-free telephone service and email
				address operating on a 24 hours/day, 7 days/week basis that accepts, receives
				and records information related to external reviews and provides appropriate
				instructions;
b. Verify name, phone number and direct email
				address of contact persons who will be responsible for handling assignments of
				external reviews;
4. Submit a check for renewal registration: $1000 if
				your company is accredited by URAC. In the event that the Director determines
				that there are no acceptable nationally recognized private accrediting entities
				providing independent review organization accreditation, a renewal fee of
				$1500; and
5. Affirmation (to be signed by an officer or
				director of the independent review organization only):
I, _________________________________________________
				do hereby certify that
(Typed name, title)
___________________________________________________________________
(Independent Review Organization)
complies with the Independent Review Organization
				Accreditation Standards of the American Accreditation Healthcare Commission
				(URAC) and has submitted evidence of accreditation by URAC for Independent
				Review, and that the persons responsible for the conduct of
				_________________________
(Independent Review Organization)
are competent, trustworthy, and possess good
				reputations, and have appropriate experience, training or education and do
				hereby affirm that all of the information presented in this application is true
				and correct.
____________________________
				___________________
(Signature)(Date)
Please mail completed renewal application
				to:
Illinois Department of Insurance
Utilization Review Unit
320 West Washington Street
Springfield IL 62767-0001
(217) 558-2309