This text of Indiana § 27-13-10-8 (Appeals of grievance decisions; filing of report for violation) is published on Counsel Stack Legal Research, covering Indiana primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.
(a)A health maintenance organization shall
establish written policies and procedures for the timely resolution of
appeals of grievance decisions. The procedures for registering and
responding to oral and written appeals of grievance decisions must
include the following:
(1)Acknowledgment of the appeal, orally or in writing, within
three (3) business days after receipt of the appeal being filed.
(2)Documentation of the substance of the appeal and the actions
taken.
(3)Investigation of the substance of the appeal, including any
aspects of clinical care involved.
(4)Notification to enrollees or subscribers of the disposition of
the appeal and that the enrollee or subscriber may have the right
to further remedies allowed by law.
(5)Standards for timeliness in responding to appeals and
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(a) A health maintenance organization shall
establish written policies and procedures for the timely resolution of
appeals of grievance decisions. The procedures for registering and
responding to oral and written appeals of grievance decisions must
include the following:
(1) Acknowledgment of the appeal, orally or in writing, within
three (3) business days after receipt of the appeal being filed.
(2) Documentation of the substance of the appeal and the actions
taken.
(3) Investigation of the substance of the appeal, including any
aspects of clinical care involved.
(4) Notification to enrollees or subscribers of the disposition of
the appeal and that the enrollee or subscriber may have the right
to further remedies allowed by law.
(5) Standards for timeliness in responding to appeals and
providing notice to enrollees or subscribers of the disposition of
the appeal and the right to initiate an external appeals process that
accommodate the clinical urgency of the situation.
(b) The health maintenance organization shall appoint a panel of
qualified individuals to resolve an appeal. An individual may not be
appointed to the panel who has been involved in the matter giving rise
to the complaint or in the initial investigation of the complaint. Except
for grievances that have previously been appealed under IC 27-8-17, in
the case of an appeal from the proposal, refusal, or delivery of a health
care procedure, treatment, or service, the health maintenance
organization shall appoint one (1) or more individuals to the panel to
resolve the appeal. The panel must include one (1) or more individuals
who:
(1) have knowledge in the medical condition, procedure, or
treatment at issue;
(2) are in the same licensed profession as the provider who
proposed, refused, or delivered the health care procedure,
treatment, or service;
(3) are not involved in the matter giving rise to the appeal or the
previous grievance process; and
(4) do not have a direct business relationship with the enrollee or
the health care provider who previously recommended the health
care procedure, treatment, or service giving rise to the grievance.
(c) An appeal of a grievance decision must be resolved as
expeditiously as possible and with regard to the clinical urgency of the
appeal. However, an appeal must be resolved not later than forty-five
(45) days after the appeal is filed. A health maintenance organization
that violates this subsection commits an unfair and deceptive act or
practice in the business of insurance under IC 27-4-1-4.
(d) If a health maintenance organization violates subsection (c), the
health maintenance organization shall file a report with the department
during the quarter in which the violation occurred concerning the
insurer's compliance with subsection (c). The report must include the
following:
(1) The number of appealed grievance decisions that were not
resolved as required under subsection (c).
(2) The reason each appeal described in subdivision (1) was not
resolved.
(e) A health maintenance organization shall allow enrollees and
subscribers the opportunity to appear in person at the panel or to
communicate with the panel through appropriate other means if the
enrollee or subscriber is unable to appear in person.
(f) A health maintenance organization shall notify the enrollee or
subscriber in writing of the resolution of the appeal of a grievance
within five (5) business days after completing the investigation. The
grievance resolution notice must contain the following:
(1) The decision reached by the health maintenance organization.
(2) The reasons, policies, or procedures that are the basis of the
decision.
(3) Notice of the enrollee's or subscriber's right to further
remedies allowed by law, including the right to review by an
independent review organization under IC 27-13-10.1.
(4) The department, address, and telephone number through
which an enrollee may contact a qualified representative to obtain
more information about the decision or the right to an appeal.