S.D. Admin. R. 20:06:53 app D
Health Carrier External Review Division of Insurance Annual Report Form
External Review Annual Summary for 20_____ | |||||
Due on ___________for previous calendar year. | |||||
Each health carrier shall submit an annual report with information in the aggregate by state and by type of health benefit plan. | |||||
1. Health carrier name: | Filing Date: | ||||
2. Health carrier address: | |||||
City, State, ZIP: | |||||
3. Health carrier Web site: | |||||
4. Name, email address, phone and fax number of the person completing this form: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ | |||||
5. Total number of external review requests received from the South Dakota Division of Insurance during the reporting period: | _______ | ||||
6. From the total number of external review requests provided in Question 5, the number of requests determined eligible for a full external review: | _______ | ||||
S.D. Admin. R. 20:06:53 app D