Indiana § 27-8-29-15 Independent review organizations; determinations

Indiana Statutes

§ 27-8-29-15 — Independent review organizations; determinations

Indiana § 27-8-29-15

Title 27INSURANCE

Art. 8LIFE, ACCIDENT, AND HEALTH

Ch. 29External Review of Grievances

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Bluebook

Ind. Code § 27-8-29-15 (2026).

Text

(a)An independent review organization shall:

(1)for an expedited external grievance filed under section 13(a)(2)(A) of this chapter, within seventy-two (72) hours after the external grievance is filed; or

(2)for a standard external grievance filed under section 13(a)(2)(B) of this chapter, within fifteen (15) business days after the external grievance is filed; make a determination to uphold or reverse the insurer's appeal resolution under IC 27-8-28-17 based on information gathered from the covered individual or the covered individual's designee, the insurer, and the treating health care provider, and any additional information that the independent review organization considers necessary and appropriate.

(b)When making the determination under this section, the independent review organ

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(a) An independent review organization
shall:
(1) for an expedited external grievance filed under section
13(a)(2)(A) of this chapter, within seventy-two (72) hours after
the external grievance is filed; or
(2) for a standard external grievance filed under section
13(a)(2)(B) of this chapter, within fifteen (15) business days after
the external grievance is filed;
make a determination to uphold or reverse the insurer's appeal
resolution under IC 27-8-28-17 based on information gathered from the
covered individual or the covered individual's designee, the insurer,
and the treating health care provider, 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 covered individual's accident and sickness
insurance policy.
(c) In an external grievance described in section 12(1)(D) of this
chapter, the insurer bears the burden of proving that the insurer
properly denied coverage for a condition, complication, service, or
treatment because the condition, complication, service, or treatment is
directly related to a condition for which coverage has been waived
under IC 27-8-5-2.5(e) (expired July 1, 2007, and removed) or IC 27-8-5-19.2 (expired July 1, 2007, and repealed).
(d) The independent review organization shall notify the insurer and
the covered individual of the determination made under this section:
(1) for an expedited external grievance filed under section
13(a)(2)(A) of this chapter, within seventy-two (72) hours after
the external grievance is filed; and
(2) for a standard external grievance filed under section
13(a)(2)(B) of this chapter, within seventy-two (72) hours after
making the determination.

Legislative History

As added by P.L.66-2001, SEC.3 and P.L.203-2001, SEC.14. Amended by P.L.211-2003, SEC.9; P.L.3-2008, SEC.218; P.L.81-2012, SEC.37; P.L.72-2016, SEC.21.