S.D. Admin. R. 20:06:53 app C

Current through Register Vol. 50, page 159, June 17, 2024

Appendix C - Independent review organization external review annual report form

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:

S.D. Admin. R. 20:06:53 app C

37 SDR 48, effective 9/22/2010.