South Dakota Administrative Rules › Title 20 - PUBLIC SAFETY › Article 20:06 - INSURANCE › Chapter 20:06:53 - External and internal review › Appendix C - Independent review organization external review annual report form

Current through Register Vol. 51, page 10, July 15, 2024
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: