<html> <head> <title>Rule 20:06:53:0C Independent Review Organization External Review Annual Report Form.</title> <META NAME="Keywords" Content="Administrative Rules 20:06:53:0C"> <META NAME="Description" Content="Administrative Rules 20:06:53:0C Independent Review Organization External Review Annual Report Form."> <meta http-equiv=Content-Type content="text/html; charset=windows-1252"> <meta name=Generator content="Microsoft Word 14 (filtered)"> <style> <!-- /* Font Definitions */ @font-face {font-family:Calibri; panose-1:2 15 5 2 2 2 4 3 2 4;} /* Style Definitions */ p.MsoNormal, li.MsoNormal, div.MsoNormal {margin:0in; margin-bottom:.0001pt; font-size:12.0pt; font-family:"Times New Roman","serif";} @page WordSection1 {size:8.5in 11.0in; margin:1.0in 1.0in 1.0in 1.0in;} div.WordSection1 {page:WordSection1;} --> </style> </head> <body lang=EN-US> <div class=WordSection1> <p class=MsoNormal style='margin-left:-.45pt;text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> <p class=MsoNormal style='margin-left:-.45pt;text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> <p class=MsoNormal style='margin-left:-.45pt;text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> <p class=MsoNormal style='margin-left:-.45pt;text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> <p class=MsoNormal style='margin-left:-.45pt;text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> <p class=MsoNormal style='margin-left:-.45pt;text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> <p class=MsoNormal style='margin-left:-.45pt;text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> <p class=MsoNormal style='margin-left:-.45pt;text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> <p class=MsoNormal style='margin-left:-.45pt;text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> <p class=MsoNormal style='margin-left:-.45pt;text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> <p class=MsoNormal style='margin-left:-.45pt;text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> <p class=MsoNormal style='margin-left:-.45pt;text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> <p class=MsoNormal align=center style='margin-left:-.45pt;text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>DEPARTMENT OF LABOR AND REGULATION</span></font></p> <p class=MsoNormal align=center style='margin-left:-.45pt;text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> <p class=MsoNormal align=center style='margin-left:-.45pt;text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>DIVISION OF INSURANCE</span></font></p> <p class=MsoNormal align=center style='margin-left:-.45pt;text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> <p class=MsoNormal align=center style='margin-left:-.45pt;text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> <p class=MsoNormal align=center style='margin-left:-.45pt;text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> <p class=MsoNormal align=center style='margin-left:-.45pt;text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> <p class=MsoNormal align=center style='margin-left:-.45pt;text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>INDEPENDENT REVIEW ORGANIZATION EXTERNAL REVIEW ANNUAL</span></font></p> <p class=MsoNormal align=center style='margin-left:-.45pt;text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>REPORT FORM</span></font></p> <p class=MsoNormal align=center style='margin-left:-.45pt;text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> <p class=MsoNormal align=center style='margin-left:-.45pt;text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> <p class=MsoNormal align=center style='margin-left:-.45pt;text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>Chapter 20:06:53</span></font></p> <p class=MsoNormal align=center style='margin-left:-.45pt;text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> <p class=MsoNormal align=center style='margin-left:-.45pt;text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>APPENDIX C</span></font></p> <p class=MsoNormal align=center style='margin-left:-.45pt;text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> <p class=MsoNormal align=center style='margin-left:-.45pt;text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>See: &#167;&nbsp;20:06:53:64</span></font></p> <p class=MsoNormal style='margin-left:-.45pt;text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> <p class=MsoNormal style='margin-left:-.45pt;text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> <p class=MsoNormal style='margin-left:-.45pt;text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> <p class=MsoNormal style='margin-left:-.45pt;text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> <p class=MsoNormal style='margin-left:-.45pt;text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> <p class=MsoNormal style='margin-left:-.45pt;text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> <p class=MsoNormal style='margin-left:-.45pt;text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> <p class=MsoNormal style='margin-left:-.45pt;text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> <p class=MsoNormal style='margin-left:-.45pt;text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> <p class=MsoNormal style='margin-left:-.45pt;text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> <p class=MsoNormal style='margin-left:-.45pt;text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> <p class=MsoNormal style='margin-left:-.45pt;text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> <p class=MsoNormal style='margin-left:-.45pt;text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> <p class=MsoNormal style='margin-left:-.45pt;text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> <p class=MsoNormal style='margin-left:-.45pt;text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> <p class=MsoNormal style='margin-left:-.45pt;text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> <p class=MsoNormal style='margin-left:-.45pt;text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Source: 37 SDR 48, effective September 22, 2010.</span></font></p> <p class=MsoNormal style='margin-left:-.45pt;text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> <font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family: "Times New Roman","serif"'><br clear=all style='page-break-before:always'> </span></font> <p class=MsoNormal style='margin-left:-.45pt;text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>Appendix C - Independent Review Organization External Review Annual Report Form</span></font></p> <p class=MsoNormal style='margin-left:-.45pt;text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> <p class=MsoNormal align=center style='margin-left:-.45pt;text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>South Dakota Division of Insurance</span></font></p> <p class=MsoNormal style='margin-left:-.45pt;text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> <p class=MsoNormal align=center style='margin-left:-.45pt;text-align:center'><b><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-weight:bold'>Independent Review Organization External Review Annual Report Form</span></font></b></p> <p class=MsoNormal style='margin-left:-.45pt;text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> <table class=MsoNormalTable border=1 cellspacing=0 cellpadding=0 width=638 style='width:478.7pt;margin-left:-.45pt;border-collapse:collapse;border:none'> <tr> <td width=638 colspan=9 valign=top style='width:478.7pt;border:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal><b><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-weight:bold'>External Review Annual Summary for 20________</span></font></b></p> <p class=MsoNormal><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> </td> </tr> <tr> <td width=638 colspan=9 valign=top style='width:478.7pt;border:solid windowtext 1.0pt; border-top:none;padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><b><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-weight:bold'>Due on [________] for previous calendar year.</span></font></b></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> </td> </tr> <tr> <td width=638 colspan=9 valign=top style='width:478.7pt;border:solid windowtext 1.0pt; border-top:none;padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>Each independent review organization (IRO) shall submit an annual report with information for each health carrier in the aggregate on external reviews performed in South Dakota only.</span></font></p> </td> </tr> <tr height=28 style='height:21.35pt'> <td width=638 colspan=9 height=28 valign=top style='width:478.7pt;border: solid windowtext 1.0pt;border-top:none;padding:0in 5.4pt 0in 5.4pt; height:21.35pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> </td> </tr> <tr> <td width=152 colspan=2 valign=top style='width:114.2pt;border:solid windowtext 1.0pt; border-top:none;padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>1.&nbsp;&nbsp;&nbsp;IRO name:</span></font></p> </td> <td width=281 colspan=5 valign=top style='width:210.75pt;border-top:none; border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> </td> <td width=79 valign=top style='width:59.25pt;border-top:none;border-left: none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>Filing</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>Date:</span></font></p> </td> <td width=126 valign=top style='width:94.5pt;border-top:none;border-left: none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> </td> </tr> <tr height=19 style='height:14.25pt'> <td width=152 colspan=2 height=19 valign=top style='width:114.2pt;border: solid windowtext 1.0pt;border-top:none;padding:0in 5.4pt 0in 5.4pt; height:14.25pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>2.&nbsp;&nbsp;&nbsp;IRO License/</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Certification no.:</span></font></p> </td> <td width=486 colspan=7 height=19 valign=top style='width:364.5pt;border-top: none;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt;height:14.25pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> </td> </tr> <tr height=19 style='height:14.25pt'> <td width=152 colspan=2 height=19 valign=top style='width:114.2pt;border: solid windowtext 1.0pt;border-top:none;padding:0in 5.4pt 0in 5.4pt; height:14.25pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>3.&nbsp;&nbsp;&nbsp;IRO address:</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> </td> <td width=486 colspan=7 height=19 valign=top style='width:364.5pt;border-top: none;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt;height:14.25pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> </td> </tr> <tr height=19 style='height:14.25pt'> <td width=152 colspan=2 height=19 valign=top style='width:114.2pt;border: solid windowtext 1.0pt;border-top:none;padding:0in 5.4pt 0in 5.4pt; height:14.25pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; City, State, Zip:</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> </td> <td width=486 colspan=7 height=19 valign=top style='width:364.5pt;border-top: none;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt;height:14.25pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> </td> </tr> <tr height=19 style='height:14.25pt'> <td width=152 colspan=2 height=19 valign=top style='width:114.2pt;border: solid windowtext 1.0pt;border-top:none;padding:0in 5.4pt 0in 5.4pt; height:14.25pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>4.&nbsp;&nbsp;&nbsp;IRO Web site:</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> </td> <td width=486 colspan=7 height=19 valign=top style='width:364.5pt;border-top: none;border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt;height:14.25pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> </td> </tr> <tr> <td width=638 colspan=9 valign=top style='width:478.7pt;border:solid windowtext 1.0pt; border-top:none;padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>5.&nbsp;&nbsp;&nbsp;Name, email address, phone and fax number of the person completing this form:</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>_____________________________________________________________________________</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>_____________________________________________________________________________</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>_____________________________________________________________________________</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>_____________________________________________________________________________</span></font></p> </td> </tr> <tr> <td width=638 colspan=9 valign=top style='width:478.7pt;border:solid windowtext 1.0pt; border-top:none;padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>6.&nbsp;&nbsp;Name and title of the person responsible for regulatory compliance and quality of</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;&nbsp;&nbsp;&nbsp; external reviews:</span></font></p> </td> </tr> <tr> <td width=104 valign=top style='width:78.2pt;border:solid windowtext 1.0pt; border-top:none;padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>Name:</span></font></p> </td> <td width=234 colspan=4 valign=top style='width:175.5pt;border-top:none; border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>_______________________</span></font></p> </td> <td width=72 valign=top style='width:.75in;border-top:none;border-left:none; border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>Title:</span></font></p> </td> <td width=228 colspan=3 valign=top style='width:171.0pt;border-top:none; border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>_______________________</span></font></p> </td> </tr> <tr> <td width=338 colspan=5 valign=top style='width:253.7pt;border:solid windowtext 1.0pt; border-top:none;padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>7.&nbsp;&nbsp;&nbsp;Total number of requests for external review</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; received from South Dakota Division of</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Insurance during the reporting period:</span></font></p> </td> <td width=300 colspan=4 valign=top style='width:225.0pt;border-top:none; border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; _____________________</span></font></p> </td> </tr> <tr> <td width=200 colspan=3 valign=top style='width:150.2pt;border:solid windowtext 1.0pt; border-top:none;padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>8.&nbsp;&nbsp;&nbsp;Number of standard</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; external reviews.</span></font></p> </td> <td width=120 valign=top style='width:1.25in;border-top:none;border-left: none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> </td> <td width=318 colspan=5 valign=top bgcolor="#D9D9D9" style='width:238.5pt; border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt; border-right:solid windowtext 1.0pt;background:#D9D9D9;padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> </td> </tr> <tr> <td width=320 colspan=4 valign=top style='width:240.2pt;border:solid windowtext 1.0pt; border-top:none;padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>9.&nbsp;&nbsp;&nbsp;Average number of days IRO required</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; to reach a final decision in standard</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; reviews:</span></font></p> </td> <td width=113 colspan=3 valign=top style='width:84.75pt;border-top:none; border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> </td> <td width=205 colspan=2 valign=top bgcolor="#D9D9D9" style='width:153.75pt; border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt; border-right:solid windowtext 1.0pt;background:#D9D9D9;padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> </td> </tr> <tr> <td width=320 colspan=4 valign=top style='width:240.2pt;border:solid windowtext 1.0pt; border-top:none;padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>10.&nbsp;Number of expedited reviews</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; completed to a final decision:</span></font></p> </td> <td width=113 colspan=3 valign=top style='width:84.75pt;border-top:none; border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> </td> <td width=205 colspan=2 valign=top bgcolor="#D9D9D9" style='width:153.75pt; border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt; border-right:solid windowtext 1.0pt;background:#D9D9D9;padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> </td> </tr> <tr height=19 style='height:14.25pt'> <td width=433 colspan=7 height=19 valign=top style='width:324.95pt; border:solid windowtext 1.0pt;border-top:none;padding:0in 5.4pt 0in 5.4pt; height:14.25pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>11.&nbsp;Average number of days IRO required to reach a final</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; decision in expedited reviews:</span></font></p> </td> <td width=205 colspan=2 height=19 valign=top style='width:153.75pt; border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt; border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:14.25pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>_____________________</span></font></p> </td> </tr> <tr height=19 style='height:14.25pt'> <td width=433 colspan=7 height=19 valign=top style='width:324.95pt; border:solid windowtext 1.0pt;border-top:none;padding:0in 5.4pt 0in 5.4pt; height:14.25pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>12.&nbsp;Number of medical necessity reviews decided in favor</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; of the health carrier:</span></font></p> </td> <td width=205 colspan=2 height=19 valign=top style='width:153.75pt; border-top:none;border-left:none;border-bottom:solid windowtext 1.0pt; border-right:solid windowtext 1.0pt;padding:0in 5.4pt 0in 5.4pt;height:14.25pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>_____________________</span></font></p> </td> </tr> <tr height=0> <td width=104 style='border:none'></td> <td width=48 style='border:none'></td> <td width=48 style='border:none'></td> <td width=120 style='border:none'></td> <td width=18 style='border:none'></td> <td width=72 style='border:none'></td> <td width=23 style='border:none'></td> <td width=79 style='border:none'></td> <td width=126 style='border:none'></td> </tr> </table> <font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family: "Times New Roman","serif"'><br clear=all style='page-break-before:always'> </span></font> <p class=MsoNormal style='margin-left:-.45pt;text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> <table class=MsoNormalTable border=1 cellspacing=0 cellpadding=0 width=649 style='margin-left:.9pt;border-collapse:collapse;border:none'> <tr> <td width=210 valign=top style='width:157.2pt;border:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>Briefly list procedures</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>denied:</span></font></p> </td> <td width=438 colspan=5 valign=top style='width:328.75pt;border:solid windowtext 1.0pt; border-left:none;padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>________________________________________________________________________________________________________</span></font></p> </td> </tr> <tr> <td width=429 colspan=3 valign=top style='width:321.7pt;border:solid windowtext 1.0pt; border-top:none;padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>13.&nbsp;Number of medical necessity reviews decided in favor of</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; the covered person:</span></font></p> </td> <td width=219 colspan=3 valign=top style='width:164.25pt;border-top:none; border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>_____________________</span></font></p> </td> </tr> <tr> <td width=210 valign=top style='width:157.2pt;border:solid windowtext 1.0pt; border-top:none;padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>Briefly list procedures </span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>approved:</span></font></p> </td> <td width=438 colspan=5 valign=top style='width:328.75pt;border-top:none; border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>____________________________________________________</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>____________________________________________________</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>____________________________________________________</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>____________________________________________________</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>____________________________________________________</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>____________________________________________________</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>____________________________________________________</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>____________________________________________________</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>____________________________________________________</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> </td> </tr> <tr> <td width=495 colspan=4 valign=top style='width:371.4pt;border:solid windowtext 1.0pt; border-top:none;padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>14.&nbsp;Number of experimental/investigational reviews decided in favor</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; of the health carrier:</span></font></p> </td> <td width=153 colspan=2 valign=top style='width:114.55pt;border-top:none; border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>_______________</span></font></p> </td> </tr> <tr> <td width=210 valign=top style='width:157.2pt;border:solid windowtext 1.0pt; border-top:none;padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>Briefly list procedures denied:</span></font></p> </td> <td width=438 colspan=5 valign=top style='width:328.75pt;border-top:none; border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>____________________________________________________</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>____________________________________________________</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>____________________________________________________</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>____________________________________________________</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>____________________________________________________</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>____________________________________________________</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>____________________________________________________</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>____________________________________________________</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>____________________________________________________</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> </td> </tr> <tr> <td width=496 colspan=5 valign=top style='width:372.1pt;border:solid windowtext 1.0pt; border-top:none;padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>15.&nbsp;Number of experimental/investigational reviews decided in favor</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; of the covered person:</span></font></p> </td> <td width=152 valign=top style='width:113.85pt;border-top:none;border-left: none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>_______________</span></font></p> </td> </tr> <tr> <td width=210 valign=top style='width:157.2pt;border:solid windowtext 1.0pt; border-top:none;padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>Briefly list procedures</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>approved:</span></font></p> </td> <td width=438 colspan=5 valign=top style='width:328.75pt;border-top:none; border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>____________________________________________________</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>____________________________________________________</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>____________________________________________________</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>____________________________________________________</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>____________________________________________________</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>____________________________________________________</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>____________________________________________________</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>____________________________________________________</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>____________________________________________________</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> </td> </tr> <tr> <td width=378 colspan=2 valign=top style='width:283.5pt;border:solid windowtext 1.0pt; border-top:none;padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>16.&nbsp;Number of reviews terminated as the result of a</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; reconsideration by the health carrier:</span></font></p> </td> <td width=271 colspan=4 valign=top style='width:203.3pt;border-top:none; border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>_________________</span></font></p> </td> </tr> <tr> <td width=378 colspan=2 valign=top style='width:283.5pt;border:solid windowtext 1.0pt; border-top:none;padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>17.&nbsp;Number of reviews terminated by the covered</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; person:</span></font></p> </td> <td width=271 colspan=4 valign=top style='width:203.3pt;border-top:none; border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>_________________</span></font></p> </td> </tr> <tr height=0> <td width=84 style='border:none'></td> <td width=248 style='border:none'></td> <td width=75 style='border:none'></td> <td width=98 style='border:none'></td> <td width=2 style='border:none'></td> <td width=423 style='border:none'></td> </tr> </table> <p class=MsoNormal style='margin-left:-.45pt;text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> <p class=MsoNormal style='margin-left:-.45pt;text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> <font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-family: "Times New Roman","serif"'><br clear=all style='page-break-before:always'> </span></font> <p class=MsoNormal style='margin-left:-.45pt;text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> <table class=MsoNormalTable border=1 cellspacing=0 cellpadding=0 style='margin-left:-.45pt;border-collapse:collapse;border:none'> <tr> <td width=308 colspan=4 valign=top style='width:231.2pt;border:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>18. Number of reviews declined due to </span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; possible conflict with:</span></font></p> </td> <td width=342 colspan=4 valign=top style='width:256.25pt;border:solid windowtext 1.0pt; border-left:none;padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> </td> <td style='border:none;border-bottom:solid windowtext 1.0pt' width=1><p class='MsoNormal'>&nbsp;</td> </tr> <tr> <td width=108 valign=top style='width:80.85pt;border:solid windowtext 1.0pt; border-top:none;padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>Health carrier</span></font></p> </td> <td width=108 valign=top style='width:81.15pt;border-top:none;border-left: none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>__________</span></font></p> </td> <td width=92 colspan=2 valign=top style='width:69.2pt;border-top:none; border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>Covered person</span></font></p> </td> <td width=125 valign=top style='width:93.9pt;border-top:none;border-left: none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>__________</span></font></p> </td> <td width=108 colspan=2 valign=top style='width:81.15pt;border-top:none; border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>Health care</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>provider</span></font></p> </td> <td width=109 colspan=2 valign=top style='width:81.65pt;border-top:none; border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>__________</span></font></p> </td> </tr> <tr> <td width=254 colspan=3 valign=top style='width:190.7pt;border:solid windowtext 1.0pt; border-top:none;padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>Describe possible conflicts(s) of</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>interest:</span></font></p> </td> <td width=396 colspan=6 valign=top style='width:297.2pt;border-top:none; border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>______________________________________________</span></font></p> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>______________________________________________</span></font></p> </td> </tr> <tr> <td width=458 colspan=6 valign=top style='width:343.7pt;border:solid windowtext 1.0pt; border-top:none;padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>19.&nbsp;Number of reviews declined due to other reasons not reflected</span></font></p> <p class=MsoNormal><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; in Question 18:</span></font></p> </td> <td width=192 colspan=3 valign=top style='width:144.2pt;border-top:none; border-left:none;border-bottom:solid windowtext 1.0pt;border-right:solid windowtext 1.0pt; padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal style='text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> </td> </tr> <tr height=0> <td width=108 style='border:none'></td> <td width=108 style='border:none'></td> <td width=38 style='border:none'></td> <td width=54 style='border:none'></td> <td width=125 style='border:none'></td> <td width=25 style='border:none'></td> <td width=83 style='border:none'></td> <td width=108 style='border:none'></td> <td width=1 style='border:none'></td> </tr> </table> <p class=MsoNormal style='margin-left:-.45pt;text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> <font size=3 face="Times New Roman"><span style='font-size:12.0pt;line-height: 115%;font-family:"Times New Roman","serif"'><br clear=all style='page-break-before: always'> </span></font> <p class=MsoNormal style='margin-bottom:10.0pt;line-height:115%'><font size=3 face="Times New Roman"><span style='font-size:12.0pt;line-height:115%'>&nbsp;</span></font></p> <p class=MsoNormal style='margin-left:-.45pt;text-align:justify'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>&nbsp;</span></font></p> </div> </body> </html>