Ill. Admin. Code tit. 50, pt. 4530, app D
INDEPENDENT REVIEW ORGANIZATION
Renewal Registration Form
[Today's Date]
Company Name: ________________________________________________________
FEIN: _________________________________________________________________
Contact Person: _________________________________________________________
Telephone: ( )____________________________________________________________
Email Address: __________________________________________________________
Street Address: __________________________________________________________
City, State, Zip: __________________________________________________________
Renewal registration for Independent Review Organization covering period __/__/__ through __/__/__.
Instructions for completing renewal registration:
1. Please verify all information regarding company name, contact person and address to be complete and accurate;
2. Submit a current copy of the applicable accreditation certificate from the American Accreditation Healthcare Commission (URAC) if applicable;
3. Submit any material changes to the information filed under your prior registration:
a. Verify toll-free telephone service and email address operating on a 24 hours/day, 7 days/week basis that accepts, receives and records information related to external reviews and provides appropriate instructions;
b. Verify name, phone number and direct email address of contact persons who will be responsible for handling assignments of external reviews;
4. Submit a check for renewal registration: $1000 if your company is accredited by URAC. In the event that the Director determines that there are no acceptable nationally recognized private accrediting entities providing independent review organization accreditation, a renewal fee of $1500; and
5. Affirmation (to be signed by an officer or director of the independent review organization only):
I, _________________________________________________ do hereby certify that
(Typed name, title)
___________________________________________________________________
(Independent Review Organization)
complies with the Independent Review Organization Accreditation Standards of the American Accreditation Healthcare Commission (URAC) and has submitted evidence of accreditation by URAC for Independent Review, and that the persons responsible for the conduct of _________________________
(Independent Review Organization)
are competent, trustworthy, and possess good reputations, and have appropriate experience, training or education and do hereby affirm that all of the information presented in this application is true and correct.
____________________________ ___________________
(Signature)(Date)
Please mail completed renewal application to:
Illinois Department of Insurance
Utilization Review Unit
320 West Washington Street
Springfield IL 62767-0001
(217) 558-2309
Ill. Admin. Code tit. 50, pt. 4530, app D