Alaska Administrative Code › Title 3 - Commerce, Community, and Economic Development › Part 2 - Division of Insurance › Chapter 28 - Life, Health, Variable, and Related Insurance › Article 12 - External Review of Health Care Coverage Decisions › 3 AAC 28.978 - External review reporting requirements

Current through May 31, 2024
(a) An independent
				  review organization assigned to conduct an external review shall maintain
				  written records, in the aggregate by state and by health care insurer, of
				  requests for external review for which the independent review organization
				  conducted external reviews during a calendar year.
(b) An independent review organization
				  required to maintain written records under this section shall submit to the
				  director, upon request, a report in a format specified by the director. The
				  report must include
(1) the name and mailing
				  address of the independent review organization;
(2) the name, title, electronic mail address,
				  telephone number, and facsimile transmission number of the person completing
				  die report;
(3) the name, title,
				  electronic mail address, telephone number, and facsimile transmission number of
				  the person responsible for regulatory compliance and quality of external
				  reviews; and
(4) in the aggregate
				  by state and by health care insurer the following:
(A) the total number of requests assigned to
				  the independent review organization for
(i)
				  standard external reviews; and
(ii)
				  expedited external reviews;
(B) the average length of time for resolution
				  of requests for external review assigned to the independent review organization
				  for
(i) standard external reviews;
				  and
(ii) expedited external
				  reviews;
(C) the number
				  of medical necessity external reviews decided in favor of a health care insurer
				  and a brief list of the procedures denied;
(D) the number of medical necessity external
				  reviews decided in favor of the covered person and a brief list of the
				  procedures approved;
(E) the number
				  of experimental or investigational treatment external reviews decided in favor
				  of the health care insurer and a brief list of the procedures denied:
(F) the number of experimental or
				  investigational treatment external reviews decided in favor of the covered
				  person and a brief list of the procedures approved;
(G) the number of external reviews terminated
				  as the result of a reconsideration by a health care insurer;
(H) the number of external reviews terminated
				  by the covered person or the covered person's authorized representative before
				  issuance by the independent review organization of the external review
				  decision;
(I) the number of
				  external reviews declined due to possible conflict of interest for each of the
				  following:
(i) a health care
				  insurer;
(ii) a covered
				  person;
(iii) a health care
				  provider;
(J) a brief
				  description of the conflicts of interest identified under (I)(i) -(iii) of this
				  paragraph;
(K) the number of
				  external reviews declined due to other reasons not reflected under (I) of this
				  paragraph.