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Internal Review, Arbitration & Independent Review of

By Anna Perkins,2014-11-25 10:57
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Internal Review, Arbitration & Independent Review of

    Internal Review, Arbitration & Independent Review of

    Health Insurance Claims Reports

    INTERNAL REVIEW

    Date Received Name of Covered Person Plan ID # Reason for Grievance Date of Final Description of Decision

    Decision

    ARBITRATION PETITION

    Date Filed Name of Covered Person Plan ID# Reason For Petition Date of Decision Arbitor’s

    Decision/Disposition

    IHCAP APPEAL

    Date Received Name of Covered Person Plan ID# Reason For Appeal Date of IURO Description of IURO

    Decision Decision

    Page 1

    Internal Review, Arbitration & Independent Review of

    Health Insurance Claims Reports

STATISTICS

Grievances

    Total Number Filed ____________

Petitions for Arbitration

    Total Number Filed ____________

    Total Number of Decisions Upheld ____________

    Total Number of Decisions Reversed ____________

IHCAP

    Total Number of IHCAP Filed ____________

    Total Number of Decisions Upheld ____________

    Total Number Decisions Reversed __________

    Name of Company:________________________________________________________________________________ NAIC No. ____________________

    Address: ________________________________________________________________________________________________________________________

    Completed By: _____________________________________________________________________ Title: _______________________________________

    E-Mail Address: _________________________________________________ Phone No. ________________________ Fax No. _____________________

Date: ___________________________

    Page 2

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