§ 58-50-90. External review reporting requirements.

336 words·~2 min read·/nc/chapter-58/58-50-90

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(a)An organization assigned under G.S. 58-50-80 or G.S. 58-50-82 to conduct an external review shall maintain written records in the aggregate and by insurer on all requests for external review for which it conducted an external review during a calendar year and submit a report to the Commissioner, as required under subsection

(b)of this section.

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

(a)of this section for which it was assigned to conduct an external review shall submit to the Commissioner, upon the Commissioner's request, a report in the format specified by the Commissioner.

(c)The report shall include in the aggregate and for each insurer:

(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 noncertification appeal decision or second-level grievance review decision and the number resolved reversing the noncertification appeal decision or second-level grievance review decision.

(3)The average length of time for resolution.

(4)A 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 under G.S. 58-50-80 that were terminated as the result of a reconsideration by the insurer of its noncertification appeal decision or second-level grievance review decision after the receipt of additional information from the covered person.

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

(d)The organization shall retain the written records required under this section for at least three years.

(e)Each insurer shall maintain written records in the aggregate and for each type of health benefit plan offered by the insurer on all requests for external review of which the insurer receives notice from the Commissioner under this Part. The insurer shall retain the written records required under this section for at least three years. (2001-446, s. 4.5; 2009-382, s. 32.)