Fillable INSURERS PETITION FOR EXTERNAL REVIEW DELAWARES INDEPENDENT HEALTH (Department of Technology and Information)

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INSURERS PETITION FOR EXTERNAL REVIEW DELAWARES INDEPENDENT HEALTH (Department of Technology and Information)

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INSURER’S PETITION FOR EXTERNAL REVIEW
DELAWARE’S INDEPENDENT HEALTH CARE APPEALS PROGRAM
DELAWARE DEPARTMENT OF INSURANCE
Carrier:
Carrier Name & NAIC # Address
Contact Person Title Phone
__________________________
Email
Appellant (person filing the appeal):
Appellant Address
Best way to contact Home phone (hrs available) Other phone (hrs available)
Relationship to enrollee Email Address
Enrollee (person the appeal concerns):
Enrollee Address
Best way to contact Home phone (hrs available) Other phone (hrs available)
Relationship to enrollee Plan type (indiv, small group, large group-self
funded or fully insured)
*Multi-State plans are not eligible for state appeals
Insured (person in whose name the policy is
written):
Insured Address
Best way to contact Home phone (hrs available) Other phone (hrs available)
Relationship to enrollee Email Address
Policy identification numbers
Please Select One
Please Select One
Please Select One
Case specifics:
Appeal identifier assigned by carrier
(number etc.)
Diagnostic Category (cardiac, inpatient,
musculoskeletal, surgery, e/r, etc.)
Date appellant requested Preliminary
appeal.
Date completed Preliminary Review.
Date Preliminary (or final) Decision sent
to covered person
Date appellant requested stage 2
appeal.
Date stage 2 appeal occurred.
Date appellant notified of stage 2
adverse determination
Amount in Dispute
Composition of panel (list by license
and specialty
Date appellant requested External
appeal (access to IHCAP).
Date Preliminary Decision sent to DOI.
Directions for completing form:
1. Complete form/petition in its entirety.
2. Incomplete forms will be rejected.
3. Email this form/petition via secured email to: IURO@delaware.gov, subject line:
“Petition for IURO” as soon as possible, but no more than 3 business days after
appellant’s request for review under IHCAP.
4. After the Independent Utilization Review Organization (IURO) is identified, you will be
expected to forward your evidentiary material to that company.
5. Submit any additional questions via email to: IURO@delaware.gov.
***Consumers enrolled in Multi-State Plan (MSP) coverage are entitled to request an external
review from Office Personnel Management (OPM). MSP enrollees may request an external
review by calling (855) 318-0714, or e-mailing OPM at mspp@opm.gov. Additional information
may be found on the OPM website: http://www.opm.gov/healthcare-insurance/multi-state-
planprogram/external-review/.
DE DOI 06/2019
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INSURERS PETITION FOR EXTERNAL REVIEW DELAWARES INDEPENDENT HEALTH (Department of Technology and Information)

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Completed 20 July 2020

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