<html> <head> <title>Rule 20:06:53:0D Model Health Carrier External Annual Report Form.</title> <META NAME="Keywords" Content="Administrative Rules 20:06:53:0D"> <META NAME="Description" Content="Administrative Rules 20:06:53:0D Model Health Carrier External 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 Definitions */ @page WordSection1 {size:8.5in 11.0in; margin:49.7pt 1.0in 49.7pt 63.35pt;} 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'>MODEL HEALTH CARRIER EXTERNAL REVIEW ANNUAL 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 D</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;20:06:53:65</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;</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> <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 D - Model Health Carrier 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'><b><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-weight:bold'>Health Carrier External Review Division of Insurance 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 style='margin-left:-.45pt;border-collapse:collapse;border:none'> <tr> <td width=644 colspan=6 valign=top style='width:483.2pt;border:solid windowtext 1.0pt; 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'>External Review Annual Summary for 20_____</span></font></b></p> </td> </tr> <tr> <td width=644 colspan=6 valign=top style='width:483.2pt;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'>&nbsp;</span></font></p> </td> </tr> <tr> <td width=314 colspan=2 valign=top style='width:235.85pt;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</span></font></b></p> <p class=MsoNormal style='text-align:justify'><b><font size=3 face="Times New Roman"><span style='font-size:12.0pt;font-weight:bold'>year.</span></font></b></p> </td> <td width=330 colspan=4 valign=top style='width:247.35pt;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> <td width=644 colspan=6 valign=top style='width:483.2pt;border:solid windowtext 1.0pt; border-top:none;padding:0in 5.4pt 0in 5.4pt'> <p class=MsoNormal align=center style='text-align:center'><font size=3 face="Times New Roman"><span style='font-size:12.0pt'>Each health carrier shall submit an annual report with information in the aggregate by state and by type of health benefit plan.</span></font></p> </td> </tr> <tr> <td width=644 colspan=6 valign=top style='width:483.2pt;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'>&nbsp;</span></font></p> </td> </tr> <tr> <td width=195 valign=top style='width:145.9pt;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;Health carrier name:</span></font></p> </td> <td width=204 colspan=2 valign=top style='width:152.9pt;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'>&nbsp;</span></font></p> </td> <td width=89 valign=top style='width:66.85pt;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'>Filing Date:</span></font></p> </td> <td width=157 colspan=2 valign=top style='width:117.55pt;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'>&nbsp;</span></font></p> </td> </tr> <tr> <td width=195 valign=top style='width:145.9pt;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'>2.&nbsp;&nbsp;Health carrier</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; address:</span></font></p> </td> <td width=450 colspan=5 valign=top style='width:337.3pt;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'>&nbsp;</span></font></p> </td> </tr> <tr> <td width=195 valign=top style='width:145.9pt;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'>&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=450 colspan=5 valign=top style='width:337.3pt;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'>&nbsp;</span></font></p> </td> </tr> <tr> <td width=195 valign=top style='width:145.9pt;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'>3.&nbsp;&nbsp;Health carrier Web</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; site:</span></font></p> </td> <td width=450 colspan=5 valign=top style='width:337.3pt;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'>&nbsp;</span></font></p> </td> </tr> <tr> <td width=644 colspan=6 valign=top style='width:483.2pt;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'>4.&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> <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=572 colspan=5 valign=top style='width:429.2pt;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'>5.&nbsp;&nbsp;Total number of external review requests received from the South Dakota Division</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; of Insurance during the reporting period:</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'>_______</span></font></p> </td> </tr> <tr> <td width=572 colspan=5 valign=top style='width:429.2pt;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'>6.&nbsp;&nbsp;From the total number of external review requests provided in Question 5, the </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; number of requests determined eligible for a full external review:</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'>_______</span></font></p> </td> </tr> <tr height=0> <td width=195 style='border:none'></td> <td width=120 style='border:none'></td> <td width=84 style='border:none'></td> <td width=89 style='border:none'></td> <td width=85 style='border:none'></td> <td width=72 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> </div> </body> </html>