P.R. Laws tit. 26, § 9515
(a)
(1) Any independent review organization shall maintain written records of all external reviews it conducted during a calendar year and submit a report to the Commissioner, as required under clause (2) of this subsection. Such reports shall be made with respect to each health insurance organization or issuer individually and in the aggregate.
(2) Each independent review organization shall submit to the Commissioner at least once a year a report regarding the external reviews it conducted during the preceding calendar year in the format specified by the Commissioner.
(3) The report shall include the following information and for each health insurance organization or issuer specifically and in the aggregate:
(A) The total number of requests for external review;
(B) the number of requests for external review resolved and, of those resolved, the number resolved upholding and the number resolved reversing determinations;
(C) the average length of time for resolution;
(D) a summary of the types of coverages or cases for which an external review was sought, as provided in the format required by the Commissioner;
(E) the number of external reviews that were terminated as a result of reconsideration by the health insurance organization or issuer after the receipt of additional information from the covered person or enrollee, and
(F) any other information the Commissioner may request or require.
(4) The independent review organization shall retain the written records required under this section for at least six (6) years.
(b)
(1) Each health insurance organization or issuer shall maintain written records, in the aggregate and for each type of health plan offered, on all requests for external review filed against them.
(2) Each health insurance organization or issuer shall submit to the Commissioner, upon request, a report on all requests for external review filed against them in the format specified by the Commissioner.
(3) The report shall include in the aggregate and specifically by each type of health plan:
(A) The total number of requests for external review.
(B) From the total number of requests for external review, the number of requests determined eligible for a full external review.
(C) Any other information the Commissioner may request or require.
(4) The health insurance organization or issuer shall retain the written records required under this section for at least six (6) years.
History —Aug. 29, 2011, No. 194, added as § 28.160 on Aug. 23, 2012, No. 203, § 7, eff. 90 days after Aug. 23, 2012.