Iowa Admin. Code r. 191 app D
(Attach information to this form if necessary.)
External Review Annual Summary for 20__
Each health carrier shall submit upon request of the Commissioner an annual report with information in the aggregate for Iowa and by type of health benefit plan.
1. Health carrier name:
2. Health carrier address:
3. Health carrier Web site:
4. Name, email address, telephone number and fax number of the person completing this form:
5. Name, title, email address, telephone number and fax number of the person responsible for regulatory compliance:
6. Total number of external review requests of the health carrier's adverse determinations and final adverse determinations received from the Iowa Insurance Division during the reporting period:
7. From the total number of external review requests provided in Question 6, the number of requests determined eligible for an external review:
8. Total number of external review requests resolved and, of those resolved, the number resolved upholding the adverse determination or final adverse determination of the health carrier and the number resolved reversing the adverse determination or final adverse determination of the health carrier:
9. Total number of external review requests that were terminated as the result of a reconsideration by the health carrier of its adverse determination or final adverse determination after the receipt of additional information from the covered person or the covered person's authorized representative:
Iowa Admin. Code r. 191 app D