[ §432E-41] External review reporting requirements.

421 words·~2 min read·/hi/432e-41

A research copy — for the controlling text, always check the official state or federal source. Not legal advice.

(a)An independent review organization assigned pursuant to this part to conduct an external review shall maintain written records in the aggregate by state and by health carrier on all requests for external review for which it conducted an external review during a calendar year and upon request shall submit a report to the commissioner, as required under subsection (b).

(b)Each independent review organization required to maintain written records on all requests for external review pursuant to subsection

(a)for which it was assigned to conduct an external review shall submit to the commissioner, upon request, a report in the format specified by the commissioner. The report shall include in the aggregate by state, and for each health carrier:

(1)The total number of requests for external review;

(2)The number of requests for external review resolved and, of those resolved, the number resolved upholding the adverse action and the number resolved reversing the adverse action;

(3)The average length of time for resolution;

(4)The summary of the types of coverages or cases for which an external review was sought, as provided in the format required by the commissioner;

(5)The number of external reviews that were terminated as the result of a reconsideration by the health carrier of its adverse action after the receipt of additional information from the enrollee or the enrollee's appointed representative; and

(6)Any other information the commissioner may request or require.

The independent review organization shall retain the written records required pursuant to this subsection for at least three years.

(c)Each health carrier shall maintain written records in the aggregate, by state and for each type of health benefit plan offered by the health carrier on all requests for external review that the health carrier receives notice of from the commissioner pursuant to this part.

Each health carrier required to maintain written records on all requests for external review shall submit to the commissioner, upon request, a report in the format specified by the commissioner that includes in the aggregate, by state, and by type of health benefit plan:

(1)The total number of requests for external review;

(2)From the total number of requests for external review reported, the number of requests determined eligible for a full external review; and

(3)Any other information the commissioner may request or require.

The health carrier shall retain the written records required pursuant to this subsection for at least three years. [L 2011, c 230, pt of §2]