Iowa Admin. Code agency 191, HEALTH BENEFIT PLANS, ch. 76, app C
(Attach information to this form if necessary.)
External Review Annual Summary for 20__
Each independent review organization (IRO) shall submit upon request of the Commissioner an annual report with information for each health carrier in the aggregate for Iowa on external reviews performed and by type of health benefit plan.
1. IRO name:
Filing date:
2. IRO address:
3. IRO Web site:
4. Name, email address, telephone number and fax number of the person completing this form:
5. Name, title, email address, telephone number and fax number of the person responsible for regulatory compliance and quality of external reviews:
6. Total number of requests for external review received from the Iowa Insurance Division during the reporting period:
7. Number of standard external reviews:
8. Average number of days the IRO required to reach a final decision in standard reviews:
9. Number of expedited reviews completed to a final decision:
10. Average number of days the IRO required to reach a final decision in expedited reviews:
11. Number of medical necessity reviews decided in favor of the health carrier:
Briefly list procedures denied:
12. Number of medical necessity reviews decided in favor of the covered person/patient:
Briefly list procedures approved:
13. Number of experimental/investigational reviews decided in favor of the health carrier:
Briefly list procedures denied:
14. Number of experimental/investigational reviews decided in favor of the covered person/patient:
Briefly list procedures approved:
15. Number of reviews terminated as the result of a reconsideration by the health carrier:
16. Number of reviews terminated by the covered person/patient prior to issuance by the IRO of external review decision:
17. Number of reviews declined due to possible conflict with:
Health carrier:
Covered person/patient:
Health care provider:
Describe possible conflicts of interest:
18. Number of reviews declined due to other reasons not reflected in #17 above:
Iowa Admin. Code agency 191, HEALTH BENEFIT PLANS, ch. 76, app C