§ 27-13-10.1-8 — Certification of independent review organizations

Indiana § 27-13-10.1-8

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

Text

(a) The department shall establish and
maintain a process for annual certification of independent review
organizations.
(b) The department shall certify a number of independent review
organizations determined by the department to be sufficient to fulfill
the purposes of this chapter.
(c) An independent review organization shall meet the following
minimum requirements for certification by the department:
(1) Medical review professionals assigned by the independent
review organization to perform external grievance reviews under
this chapter:
(A) must be board certified in the specialty in which an
enrollee's proposed service would be provided;
(B) must be knowledgeable about a proposed service through
actual clinical experience;
(C) must hold an unlimited license to practice in a state of the
United States; and
(D) must have no history of disciplinary actions or sanctions
including:
(i) loss of staff privileges; or
(ii) restriction on participation;
taken or pending by any hospital, government, or regulatory
body.
(2) The independent review organization must have a quality
assurance mechanism to ensure the:
(A) timeliness and quality of reviews;
(B) qualifications and independence of medical review
professionals;
(C) confidentiality of medical records and other review
materials; and
(D) satisfaction of enrollees with the procedures utilized by the
independent review organization, including the use of enrollee
satisfaction surveys.
(3) The independent review organization must file with the
department the following information before March 1 of each
year:
(A) The number and percentage of determinations made in
favor of enrollees.
(B) The number and percentage of determinations made in
favor of health maintenance organizations.
(C) The average time to process a determination.
(D) The number of external grievance reviews terminated due
to reconsideration of the health maintenance organization
before a determination was made.
(E) Any other information required by the department.
The information required under this subdivision must be specified
for each health maintenance organization for which the
independent review organization performed reviews during the
reporting year.
(4) The independent review organization must retain all records
related to an external grievance review for at least three (3) years
after a determination is made under section 4 of this chapter.
(5) Any additional requirements established by the department.
(d) The department may not certify an independent review
organization that is one (1) of the following:
(1) A professional or trade association of health care providers or
a subsidiary or an affiliate of a professional or trade association
of health care providers.
(2) A health insurer, health maintenance organization, or health
plan association or a subsidiary or an affiliate of a health insurer,
health maintenance organization, or health plan association.
(e) The department may suspend or revoke an independent review
organization's certification if the department finds that the independent
review organization is not in substantial compliance with the
certification requirements under this section.
(f) The department shall make available to health maintenance
organizations a list of all certified independent review organizations.
(g) The department shall make the information provided to the
department under subsection (c)(3) available to the public in a format
that does not identify individual enrollees.

Legislative History

As added by P.L.133-1999, SEC.7. Amended by P.L.14-2000, SEC.60; P.L.160-2011, SEC.30.