Utilization Review Licensing in New Hampshire

Application for Certification as an Independent Review Organization

$0

• List of references, preferably other state insurance departments
• Copy of applicant’s certificate of IRO accreditation (e.g., NCQA or URAC certificates)
• Copy of applicant’s organization chart, identifying officers and key staff positions

$0

Biennially

$0

Annually

Reports must include:

• The total number of requests for external review assigned by the commissioner to the independent review organization
• The total number of requests for external review assigned by the commissioner to the independent review organization for which a final adjudication was made, and, of those, the number resolved upholding the adverse determination or final adverse determination and the number resolved reversing the adverse determination or final adverse determination
• The average length of time required for the adjudication
• A summary of the types of coverages or cases for which an external review was sought
• The number of external reviews that were terminated prior to completion as the result of a reconsideration and reversal by the health carrier of its adverse determination or final adverse determination after the receipt of new or additional information from the covered person or the covered person’s authorized representative
• The number of external reviews that were terminated prior to completion as the result of a settlement between the health carrier and the covered person on terms other than the original determination of the health carrier or a complete reversal of that determination
• The number of external reviews that were terminated prior to completion for other reasons
• Verification that the organization maintains written records fully documenting requests for external review received from the commissioner

Application for License as a Medical Utilization Review Entity

$500

• List of states where the entity does business
• List of principal proprietors, partners, directors, officers and administrators and others responsible for the operation, management and control of the entity
• Biographical sketches of all persons listed in the above requirement
• List of office locations including numbers of employees at those locations
• A description of the types of review the entity offers
• Copies of all materials used by the applicant to inform beneficiaries of the requirements of the utilization review plan and the rights and responsibilities of beneficiaries under the plan
• A description of the procedures established by the applicant for preserving the confidentiality of medical information used in the utilization review process
• A copy of the accreditation certificate received from URAC (if applicable)

Application for License as a Medical Utilization Review Entity

$100

Annually by March 31.