Form HIPMC-IRE-2 "Assignment of Independent Review Entity Form" - Kentucky

What Is Form HIPMC-IRE-2?

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-2 by clicking the link below or browse more documents and templates provided by the Kentucky Department of Insurance.

ADVERTISEMENT
ADVERTISEMENT

Download Form HIPMC-IRE-2 "Assignment of Independent Review Entity Form" - Kentucky

Download PDF

Fill PDF online

Rate (4.3 / 5) 13 votes
Page background image
Kentucky Department of Insurance
Assignment of Independent Review Entity Form
Instructions
This form is to be used by an Insurer or its designee to report the assignment of an external review (ER)
to an independent review entity (IRE). Please complete this form and email to the Division of the Health
Insurance Policy and Managed Care, Utilization Review Registration and Appeals Branch at
DOI.UtilizationReview@ky.gov
within one business day of assignment. If you have any questions, please
contact ER staff at 502-564-6088.
Name of Insurer
___________________________
Insurer’s ER Coordinator
Check if KENTUCKY EMPLOYEE HEALTH PLAN MEMBER
Name
___________________
Address
___________________
___________________
E-mail Address ___________________
Phone #
___________________
Fax #
___________________
Date Insurer received request for ER _____________________________
Specific Service denied__________________________________________________________________
Category of ER (check one)
______ Inpatient/Residential
______ Outpatient Services
______ Prescription Drugs
______ Durable Medical Equipment
______ Laboratory
______ Other (explain): _______________________________________
Name/address of covered person: _________________________________________________________
_____________________________________________________________________________________
ER relates to: (check one)
______ Adverse Determination ______ Coverage Denial/Medical Issue
Is this request for an expedited ER? (check one)
______ Yes
______ No
Name of Assigned IRE ___________________________________________________________________
Date IRE accepted assignment ____________________________________________________________
HIPMC-IRE-2 09/2020
Page 1 of 1
Kentucky Department of Insurance
Assignment of Independent Review Entity Form
Instructions
This form is to be used by an Insurer or its designee to report the assignment of an external review (ER)
to an independent review entity (IRE). Please complete this form and email to the Division of the Health
Insurance Policy and Managed Care, Utilization Review Registration and Appeals Branch at
DOI.UtilizationReview@ky.gov
within one business day of assignment. If you have any questions, please
contact ER staff at 502-564-6088.
Name of Insurer
___________________________
Insurer’s ER Coordinator
Check if KENTUCKY EMPLOYEE HEALTH PLAN MEMBER
Name
___________________
Address
___________________
___________________
E-mail Address ___________________
Phone #
___________________
Fax #
___________________
Date Insurer received request for ER _____________________________
Specific Service denied__________________________________________________________________
Category of ER (check one)
______ Inpatient/Residential
______ Outpatient Services
______ Prescription Drugs
______ Durable Medical Equipment
______ Laboratory
______ Other (explain): _______________________________________
Name/address of covered person: _________________________________________________________
_____________________________________________________________________________________
ER relates to: (check one)
______ Adverse Determination ______ Coverage Denial/Medical Issue
Is this request for an expedited ER? (check one)
______ Yes
______ No
Name of Assigned IRE ___________________________________________________________________
Date IRE accepted assignment ____________________________________________________________
HIPMC-IRE-2 09/2020
Page 1 of 1