Looking for a New Hampshire Legal Forms And Templates? Download it for free!

Form Ins-Murl - Application For License As A Medical Utilization Review Entity - Insurance Department - New Hampshire Page 3

Attach separate sheets of paper giving biographical sketches of all

persons listed under question 7. Include, at least, the person’s current

home address, current position(s), education and previous experience.

The applicant has

employees in New Hampshire and

employees nationally.

10.

Locations. List all locations from which operations are conducted whether

in or outside of New Hampshire. Show the range of activities and the

number of employees at each location. Attach a separate sheet if

necessary.

Location (City and State)

Activities

No. of Employees

11.

Describe the types of medical utilization review programs offered by the

applicant, including but not limited to:

Second opinion program;

Hospital preadmission review;

Pre-inpatient service eligibility certification and

Concurrent hospital review to determine appropriate length of stay.

IT IS REQUESTED THAT THE APPLICANT PROVIDE THE

INFORMATION REQUESTED BY ITEM 11 ON SEPARATE SHEETS OF

PAPER ATTACHED TO THE APPLICATION FORM.

12.

Describe the process by which the applicant proposes to perform each of

the utilization review services listed under (11) above. Specify (1) The

steps followed by the applicant’s personnel as they perform each type of

review program; and (2) the categories of health care personnel that

perform medical utilization review for the applicant, and whether those

persons are licensed in this or any other state.

IT IS REQUESTED THAT THE APPLICANT PROVIDE THE

INFORMATION REQUESTED BY ITEM 11 ON SEPARATE SHEETS OF

PAPER ATTACHED TO THE APPLICATION FORM.

13.

On separate sheets of paper attached to the application form, describe the

process that the applicant will use to address beneficiary and provider

complaints, requests for redeterminations and appeals.

Form Ins-Murl - Application For License As A Medical Utilization Review Entity - Insurance Department - New Hampshire Page 3