Ill. Admin. Code tit. 50, 4530 app D - Independent Review Organizations - Application for Reapproving Independent Review Organizations

Current through Register Vol. 46, No. 15, April 8, 2022

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

Notes

Ill. Admin. Code tit. 50, 4530 app D
Recodified from APPENDIX E at 41 Ill. Reg. 4990. Amended at 39 Ill. Reg. 4077, effective September 1, 2015

The following state regulations pages link to this page.



State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.