§ 58-50-90. External review reporting requirements. - North Carolina Statutes

§ 58‑50‑90. External review reporting requirements.

(a)        An organizationassigned under G.S. 58‑50‑80 or G.S. 58‑50‑82 toconduct an external review shall maintain written records in the aggregate andby insurer on all requests for external review for which it conducted anexternal review during a calendar year and submit a report to the Commissioner,as required under subsection (b) of this section.

(b)        Each organizationrequired to maintain written records on all requests for external review undersubsection (a) of this section for which it was assigned to conduct an externalreview shall submit to the Commissioner, upon the Commissioner's request, areport in the format specified by the Commissioner.

(c)        The report shallinclude in the aggregate and for each insurer:

(1)        The total number ofrequests for external review.

(2)        The number ofrequests for external review resolved and, of those resolved, the numberresolved upholding the noncertification appeal decision or second‑levelgrievance review decision and the number resolved reversing thenoncertification appeal decision or second‑level grievance reviewdecision.

(3)        The average lengthof time for resolution.

(4)        A summary of thetypes of coverages or cases for which an external review was sought, as providedin the format required by the Commissioner.

(5)        The number ofexternal reviews under G.S. 58‑50‑80 that were terminated as theresult of a reconsideration by the insurer of its noncertification appealdecision or second‑level grievance review decision after the receipt ofadditional information from the covered person.

(6)        Any otherinformation the Commissioner may request or require.

(d)        The organizationshall retain the written records required under this section for at least threeyears.

(e)        Each insurer shallmaintain written records in the aggregate and for each type of health benefitplan offered by the insurer on all requests for external review of which theinsurer receives notice from the Commissioner under this Part. The insurershall retain the written records required under this section for at least threeyears.  (2001‑446,s. 4.5; 2009‑382, s. 32.)