Form HIPMC-IRE-4 "Annual Independent Review Entity Report Form" - Kentucky

What Is Form HIPMC-IRE-4?

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-4 by clicking the link below or browse more documents and templates provided by the Kentucky Department of Insurance.

ADVERTISEMENT
ADVERTISEMENT

Download Form HIPMC-IRE-4 "Annual Independent Review Entity Report Form" - Kentucky

Download PDF

Fill PDF online

Rate (4.4 / 5) 34 votes
Page background image
Kentucky Department of Insurance
Division of Health, Life Insurance and Managed Care
Annual Independent Review Entity Report Form
IRE Name:________________________________________________
Reporting period: __________________________________________
Assignments accepted
Assignments rejected
Adverse determinations: number of denials overturned
Adverse determinations: number of denials upheld
Coverage denials requiring resolution of medical issue: number of denials overturned
Coverage denials requiring resolution of medical issue: number of denials upheld
Number of extensions taken for expedited external reviews
Number of extensions taken for non-expedited external reviews
Number of external reviews not completed in a timely manner
Number of external reviews for which filing fee was waived
Number of external reviews for which filing fee was refunded
Number of external reviews for which filing fee was collected
Number of external reviews for which filing fee was billed but not collected
HIPMC-IRE-4
09/2020
Page 1 of 1
Kentucky Department of Insurance
Division of Health, Life Insurance and Managed Care
Annual Independent Review Entity Report Form
IRE Name:________________________________________________
Reporting period: __________________________________________
Assignments accepted
Assignments rejected
Adverse determinations: number of denials overturned
Adverse determinations: number of denials upheld
Coverage denials requiring resolution of medical issue: number of denials overturned
Coverage denials requiring resolution of medical issue: number of denials upheld
Number of extensions taken for expedited external reviews
Number of extensions taken for non-expedited external reviews
Number of external reviews not completed in a timely manner
Number of external reviews for which filing fee was waived
Number of external reviews for which filing fee was refunded
Number of external reviews for which filing fee was collected
Number of external reviews for which filing fee was billed but not collected
HIPMC-IRE-4
09/2020
Page 1 of 1