DEPARTMENT OF LABOR AND REGULATION
DIVISION OF INSURANCE
MODEL HEALTH CARRIER EXTERNAL REVIEW ANNUAL REPORT FORM
Chapter 20:06:53
APPENDIX D
SEE: § 20:06:53:65
Source: 37 SDR 48, effective September 22, 2010.
Appendix D - Model Health Carrier External Review Annual Report Form
Health Carrier External Review Division of Insurance Annual Report Form
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External Review Annual Summary for 20_____ |
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Due on ___________for previous calendar year. |
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Each health carrier shall submit an annual report with information in the aggregate by state and by type of health benefit plan. |
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1. Health carrier name: |
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Filing Date: |
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2. Health carrier address: |
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City, State, ZIP:
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3. Health carrier Web site: |
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4. Name, email address, phone and fax number of the person completing this form: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
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5. Total number of external review requests received from the South Dakota Division of Insurance during the reporting period: |
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6. From the total number of external review requests provided in Question 5, the number of requests determined eligible for a full external review: |
_______ |
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