TITLE 41

INSURANCE

CHAPTER 59

IDAHO HEALTH CARRIER EXTERNAL REVIEW ACT

41-5914.  external review reporting requirements.  (1) An independent review organization assigned pursuant to this chapter to conduct an external review shall maintain written records in the aggregate for Idaho by health carrier on all requests for external review for which it conducted an external review during a calendar year and, upon request, submit a report to the director, as required under this section. Each independent review organization required to maintain written records on all requests for external review pursuant to this section for which it was assigned to conduct an external review shall submit to the director, upon request or at specified intervals, a report in the format specified by the director.

(2)  The report shall include in the aggregate for Idaho for each health carrier:

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

(b)  The number of requests for external review resolved and, of those resolved, the number resolved upholding the final adverse benefit determinations and the number resolved reversing the final adverse benefit determinations;

(c)  The average length of time for resolution;

(d)  A summary of the types of coverages or cases for which an external review was sought;

(e)  The number of external reviews pursuant to section 41-5908(18), Idaho Code, that were terminated as the result of a reconsideration by the health carrier of its final adverse benefit determination after the receipt of additional information from the covered person; and

(f)  Any other information the director may reasonably request or require.

(3)  The independent review organization shall retain the written records required pursuant to this section for at least five (5) years.

(4)  Each health carrier shall maintain written records in the aggregate for Idaho 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 director pursuant to this chapter.

(5)  Each health carrier is required to maintain written records on all requests for external review pursuant to subsection (1) of this section and shall submit to the director, upon request or at specified intervals, a report in the format specified by the director. The report shall include in the aggregate for Idaho and by type of health benefit plan:

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

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

(c)  Any other information the director may reasonably request or require.

(6)  The health carrier shall retain the written records required pursuant to this section for at least five (5) years.

History:

[41-5914, added 2009, ch. 87, sec. 1, p. 255.]