Form HIPMC-IRE-6 "External Review Information Face Sheet" - Kentucky

What Is Form HIPMC-IRE-6?

This is a legal form that was released by the Kentucky Department of Insurance - a government authority operating within Kentucky. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on September 1, 2020;
  • The latest edition provided by the Kentucky Department of Insurance;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form HIPMC-IRE-6 by clicking the link below or browse more documents and templates provided by the Kentucky Department of Insurance.

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Download Form HIPMC-IRE-6 "External Review Information Face Sheet" - Kentucky

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Kentucky Department of Insurance
External Review Information Face Sheet
This form is for use by the insurer or private review agent assigning the external review. The completed
form shall accompany the information identified on page 2 submitted to the Independent Review Entity
(IRE).
Insurer/private review agent
Company Name:
__________________________________________________________
Contact name:
__________________________________________________________
Address:
__________________________________________________________
__________________________________________________________
Phone #:
_________________________________________________________________
Fax #:
_________________________________________________________________
Covered Person, Authorized Person, or Provider requesting External Review
Name:
_________________________________________________________________
Address:
_________________________________________________________________
_________________________________________________________________
Phone #:
_________________________________________________________________
Primary Treating Provider(s) that IRE may contact for additional information
Name and Specialty/subspecialty:
_____________________________________________
Address:
_________________________________________________________________
_________________________________________________________________
Phone #:
_________________________________________________________________
Type of External Review (check one):
 Adverse determination
 Coverage denial that requires resolution of a medical issue
Category of External Review (check one):
 Inpatient/Residential Services
 Outpatient Services
 Durable Medical Equipment
 Prescription Drugs
 Other (explain)_______________________________________________________________
HIPMC-IRE-6
09/2020
Page 1 of 2
Kentucky Department of Insurance
External Review Information Face Sheet
This form is for use by the insurer or private review agent assigning the external review. The completed
form shall accompany the information identified on page 2 submitted to the Independent Review Entity
(IRE).
Insurer/private review agent
Company Name:
__________________________________________________________
Contact name:
__________________________________________________________
Address:
__________________________________________________________
__________________________________________________________
Phone #:
_________________________________________________________________
Fax #:
_________________________________________________________________
Covered Person, Authorized Person, or Provider requesting External Review
Name:
_________________________________________________________________
Address:
_________________________________________________________________
_________________________________________________________________
Phone #:
_________________________________________________________________
Primary Treating Provider(s) that IRE may contact for additional information
Name and Specialty/subspecialty:
_____________________________________________
Address:
_________________________________________________________________
_________________________________________________________________
Phone #:
_________________________________________________________________
Type of External Review (check one):
 Adverse determination
 Coverage denial that requires resolution of a medical issue
Category of External Review (check one):
 Inpatient/Residential Services
 Outpatient Services
 Durable Medical Equipment
 Prescription Drugs
 Other (explain)_______________________________________________________________
HIPMC-IRE-6
09/2020
Page 1 of 2
The following is a list of information to be submitted by the insurer to the IRE. Please check the box
to the left of each item, as applicable, to indicate submission to the IRE.
 A copy of the covered person’s medical records.
 A copy of the standards, criteria and clinical rationale used by the insurer to deny the treatment,
procedure, drug or device.
 A completed copy of the covered person’s health benefit plan, health insurance policy or certificate
of coverage.
 Other information used by the insurer in making its decision, if applicable.
 A copy of the insurer’s initial notice of adverse determination or notice of coverage denial.
 A copy of the request for internal appeal and any accompanying documentation.
 A copy of the insurer’s internal appeal determination letter upholding the original denial.
 A copy of the covered person’s written consent to release medical records.
 For coverage denials that require resolution of a medical issue, a copy of the letter issued by the
Kentucky Department of Insurance that directed the insurer to cover the service or afford the
covered person the opportunity for external review.
 A copy of the request for external review and any accompanying documentation.
Confirmation Date that IRE Received Full Case Information:
 Date: __________________________________
HIPMC-IRE-6
09/2020
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