19 Miss. Code. R. 3-15.14 - External Review Reporting Requirements

A.

1. An independent review organization assigned pursuant to Rule 15.07, Rule 15.08 or Rule 15.09 of this Regulation to conduct an external review shall maintain written records in the aggregate by State and 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 Commissioner, as required under paragraph (2).

2. Each independent review organization required to maintain written records on all requests for external review pursuant to paragraph (1) for which it was assigned to conduct an external review shall submit to the Commissioner, upon request, a report in the format specified by the Commissioner. The Independent Review Organization External Review Annual Report Form attached hereto as Rule 15.22 - Appendix "C" meets all form and content requirements of this section.

3. The report shall include in the aggregate by State, and 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 adverse determination or final adverse determination and the number resolved reversing the adverse determination or final adverse determination;

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, as provided in the format required by the Commissioner;

e. The number of external reviews pursuant to Rule 15.07(G) of this Regulation that were terminated as the result of a reconsideration by the health carrier of its adverse determination or final adverse determination after the receipt of additional information from the covered person or the covered person's authorized representative; and

f. Any other information the Commissioner may request or require.

4. The independent review organization shall retain the written records required pursuant to this subsection for at least three (3) years.

B.

1. Each health carrier shall maintain written records in the aggregate, by State and 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 Commissioner pursuant to this Regulation.

2. Each health carrier required to maintain written records on all requests for external review pursuant to paragraph (1) shall submit to the Commissioner, upon request, a report in the format specified by the Commissioner. The Health Carrier External Review Annual Report Form Attached hereto as Rule 15.23 - Appendix "D" meets all form and content requirements of this section.

3. The report shall include in the aggregate, by State, 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 under subparagraph (a) of this paragraph, the number of requests determined eligible for a full external review; and

c. Any other information the Commissioner may request or require.

5. The health carrier shall retain the written records required pursuant to this subsection for at least three (3) years.

Notes

19 Miss. Code. R. 3-15.14

Miss. Code Ann. § 83-5-1 (Rev. 2011); Public Law 111-148 -Mar. 23, 2010 (Patient Protection and Affordable Care Act)

Adopted 4/15/2015