Section 4530.APPENDIX D Independent Review Organizations – Application for Reapproving Independent Review Organizations

Section 4530.APPENDIX D   Independent Review

Organizations – Application for Reapproving Independent Review Organizations

INDEPENDENT REVIEW

ORGANIZATION

Renewal Registration

Form

[Today's Date]

Company Name:

FEIN:

Contact Person:

Telephone:

(     )

Email Address:

Street Address:

City, State, Zip:

Renewal registration for Independent Review Organization

covering period __/__/__ through __/__/__.

Instructions for completing renewal registration:

1.         Please

verify all information regarding company name, contact person and address to be

complete and accurate;

2.         Submit

a current copy of the applicable accreditation certificate from the American

Accreditation Healthcare Commission (URAC) if applicable;

3.         Submit

any material changes to the information filed under your prior registration:

a.         Verify

toll-free telephone service and email address operating on a 24 hours/day, 7

days/week basis that accepts, receives and records information related to

external reviews and provides appropriate instructions;

b.         Verify

name, phone number and direct email address of contact persons who will be

responsible for handling assignments of external reviews;

4.         Submit

a check for renewal registration:  $1000 if your company is accredited by

URAC.  In the event that the Director determines that there are no acceptable

nationally recognized private accrediting entities providing independent review

organization accreditation, a renewal fee of $1500; and

5.         Affirmation

(to be signed by an officer or director of the independent review organization

only):

I,

do hereby certify that

(Typed name, title)

(Independent Review Organization)

complies with the Independent

Review Organization Accreditation Standards of the American Accreditation

Healthcare Commission (URAC) and has submitted evidence of accreditation by

URAC for Independent Review, and that the persons

responsible for the conduct of

(Independent Review Organization)

are competent, trustworthy,

and possess good reputations, and have appropriate experience, training or

education and do hereby affirm that all of the information presented in this

application is true and correct.

(Signature)

(Date)

Please mail completed

renewal application to:

Illinois Department of Insurance

Utilization Review Unit

320 West Washington Street

Springfield IL 62767-0001

(217) 558-2309