§ 27-13-10.1-2 — Requirements of procedure

Indiana § 27-13-10.1-2

• Jurisdiction: Indiana
• Title 27: INSURANCE
• Art. 13: HEALTH MAINTENANCE ORGANIZATIONS
• Ch. 10.1: External Review of Grievances

Text

(a) An external grievance procedure
established under section 1 of this chapter must:
(1) allow an enrollee or the enrollee's representative to file a
written request with the health maintenance organization for an
appeal of the health maintenance organization's grievance
resolution under IC 27-13-10-8 not later than one hundred twenty
(120) days after the enrollee is notified of the resolution under IC 27-13-10-8; and
(2) provide for:
(A) an expedited appeal for a grievance related to an illness, a
disease, a condition, an injury, or a disability that would
seriously jeopardize the enrollee's:
(i) life or health; or
(ii) ability to reach and maintain maximum function; or
(B) a standard appeal for a grievance not described in clause
(A).
An enrollee may file not more than one (1) appeal of a health
maintenance organization's grievance resolution under this chapter.
(b) Subject to the requirements of subsection (d), when a request is
filed under subsection (a), the health maintenance organization shall:
(1) select a different independent review organization for each
appeal filed under this chapter from the list of independent review
organizations that are certified by the department under section 8
of this chapter; and
(2) rotate the choice of an independent review organization
among all certified independent review organizations before
repeating a selection.
(c) The independent review organizations shall assign a medical
review professional who is board certified in the applicable specialty
for resolution of an appeal.
(d) The independent review organization and the medical review
professional conducting the external review under this chapter may not
have a material professional, familial, financial, or other affiliation with
any of the following:
(1) The health maintenance organization.
(2) Any officer, director, or management employee of the health
maintenance organization.
(3) The physician or the physician's medical group that is
proposing the service.
(4) The facility at which the service would be provided.
(5) The development or manufacture of the principal drug, device,
procedure, or other therapy that is proposed by the treating
physician.
However, the medical review professional may have an affiliation
under which the medical review professional provides health care
services to enrollees of the health maintenance organization and may
have an affiliation that is limited to staff privileges at the health facility
if the affiliation is disclosed to the enrollee and the health maintenance
organization before commencing the review and neither the enrollee
nor the health maintenance organization objects.
(e) The enrollee shall not pay any of the costs associated with the
services of an independent review organization under this chapter. All
costs must be paid by the health maintenance organization.

Legislative History

As added by P.L.133-1999, SEC.7. Amended by P.L.160-2011, SEC.29; P.L.81-2012, SEC.41.