§ 27-8-28-17 — Policies and procedures for timely resolution of appeals of grievance decisions; filing of report for violation

(a) An insurer 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) Written or oral acknowledgment of the appeal not more than
five (5) business days after the appeal is 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 the covered individual:
(A) of the disposition of an appeal; and
(B) that the covered individual may have the right to further
remedies allowed by law.
(5) Standards for timeliness in:
(A) responding to an appeal; and
(B) providing notice to covered individuals of:
(i) the disposition of an appeal; and
(ii) the right to initiate an external grievance review under IC 27-8-29;
that accommodate the clinical urgency of the situation.
(b) In the case of an appeal of a grievance decision described in
section 6(1) or 6(2) of this chapter, an insurer shall appoint a panel of
one (1) or more qualified individuals to resolve an appeal. The panel
must include one (1) or more individuals who:
(1) have knowledge of the medical condition, procedure, or
treatment at issue;
(2) are licensed in the same profession and have a similar
specialty as the provider who proposed or delivered the health
care procedure, treatment, or service;
(3) are not involved in the matter giving rise to the appeal or in
the initial investigation of the grievance; and
(4) do not have a direct business relationship with the covered
individual 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:
(1) as expeditiously as possible, reflecting the clinical urgency of
the situation; and
(2) not later than forty-five (45) days after the appeal is filed.
An insurer 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 an insurer violates subsection (c), the insurer 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) An insurer shall allow a covered individual the opportunity to:
(1) appear in person before; or
(2) if unable to appear in person, otherwise appropriately
communicate with;
the panel appointed under subsection (b).
(f) An insurer shall notify a covered individual in writing of the
resolution of an appeal of a grievance decision within five (5) business
days after completing the investigation. The appeal resolution notice
must include the following:
(1) A statement of the decision reached by the insurer.
(2) A statement of the reasons, policies, and procedures that are
the basis of the decision.
(3) Notice of the covered individual's right to further remedies
allowed by law, including the right to external grievance review
by an independent review organization under IC 27-8-29.
(4) The department, address, and telephone number through
which a covered individual may contact a qualified representative
to obtain more information about the decision or the right to an
external grievance review.

Legislative History

As added by P.L.66-2001, SEC.2 and P.L.203-2001, SEC.13. Amended by P.L.1-2002, SEC.116; P.L.178-2003, SEC.72.