§ 27-13-10.1-4 — Requirements of independent review organization

Indiana § 27-13-10.1-4

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

Text

(a) An independent review organization
shall:
(1) for an expedited appeal filed under section 2(a)(2)(A) of this
chapter, within seventy-two (72) hours after the appeal is filed; or
(2) for a standard appeal filed under section 2(a)(2)(B) of this
chapter, within fifteen (15) business days after the appeal is filed;
make a determination to uphold or reverse the health maintenance
organization's grievance resolution under IC 27-13-10-8 based on
information gathered from the enrollee or the enrollee's designee, the
health maintenance organization, and the treating physician, and any
additional information that the independent review organization
considers necessary and appropriate.
(b) When making the determination under this section, the
independent review organization shall apply:
(1) standards of decision making that are based on objective
clinical evidence; and
(2) the terms of the enrollee's benefit contract.
(c) The independent review organization shall notify the health
maintenance organization and the enrollee of the determination made
under this section:
(1) for an expedited appeal filed under section 2(a)(2)(A) of this
chapter, within seventy-two (72) hours after the appeal is filed; or
(2) for a standard appeal filed under section 2(a)(2)(B) of this
chapter, within seventy-two (72) hours after making the
determination.

Legislative History

As added by P.L.133-1999, SEC.7. Amended by P.L.72-2016, SEC.26.