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Form Ins-Murl - Application For License As A Medical Utilization Review Entity - Insurance Department - New Hampshire Page 4

14.

The applicant is requested to enclose with the application 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.

15.

Has the applicant’s utilization review program been certified by the

Utilization Review Accreditation Commission (URAC)? Please check one.

Yes

Note: The applicant is requested to attach a copy of the accreditation

certificate received from URAC.

16.

List the telephone number(s), including toll-free numbers and fax

numbers, at which beneficiaries and providers may reach representatives

of the applicant. For each number listed indicate the number of lines

maintained and the hours and days of the week during which the number

is available.

Phone Number

Number of Lines

Days and Hours Available

16.a. Indicate the hours or days of the week during which calls are unanswered

or answered solely by the recordings or answering services that do not provide

access to representatives during the call.

17.

The applicant is requested to attach separate sheets of paper describing

the procedures established by the applicant for preserving the

confidentiality of medical information used in the utilization review process.

Form Ins-Murl - Application For License As A Medical Utilization Review Entity - Insurance Department - New Hampshire Page 4