CHAPTER 10. GRIEVANCE PROCEDURES
IC 27-13-10
Chapter 10. Grievance Procedures
IC 27-13-10-1
Establishment of procedures
Sec. 1. A health maintenance organization or limited servicehealth maintenance organization shall establish and maintain agrievance procedure for the resolution of grievances initiated byenrollees and subscribers of the organization. The grievanceprocedure of a health maintenance organization or limited servicehealth maintenance organization must be approved by thecommissioner.
As added by P.L.26-1994, SEC.25. Amended by P.L.191-1997,SEC.4.
IC 27-13-10-2
Examination by commissioner
Sec. 2. The commissioner may examine the grievance proceduresof health maintenance organizations and limited service healthmaintenance organizations.
As added by P.L.26-1994, SEC.25.
IC 27-13-10-3
Records of grievances
Sec. 3. A health maintenance organization or limited servicehealth maintenance organization shall maintain records regarding allgrievances of enrollees that the organization has received since theexamination by the commissioner of the grievance procedure of theorganization that immediately preceded the receipt of the grievances.
As added by P.L.26-1994, SEC.25. Amended by P.L.191-1997,SEC.5.
IC 27-13-10-4
Notice of grievance procedure
Sec. 4. (a) A health maintenance organization shall providetimely, adequate, and appropriate notice to each enrollee orsubscriber of the grievance procedure under this chapter andIC 27-13-10.1.
(b) A health maintenance organization shall prominently displayon all notices to enrollees and subscribers the telephone number andaddress at which a grievance may be filed.
(c) A written description of the enrollee's or subscriber's right tofile a grievance must be posted by the provider in a conspicuouspublic location in each facility that offers services on behalf of ahealth maintenance organization.
As added by P.L.191-1997, SEC.6. Amended by P.L.133-1999,SEC.5.
IC 27-13-10-5
Filing; oral or written grievance; telephone number; date Sec. 5. (a) An enrollee or a subscriber may file a grievance orallyor in writing.
(b) A health maintenance organization shall make available toenrollees and subscribers a toll free telephone number through whichgrievances may be filed. The toll free number must:
(1) be staffed by a qualified representative of the healthmaintenance organization;
(2) be available for at least forty (40) normal business hours perweek; and
(3) accept grievances in the languages of the major populationgroups served.
(c) A grievance is considered to be filed on the first date it isreceived, either by telephone or in writing.
As added by P.L.191-1997, SEC.7.
IC 27-13-10-6
Filing; procedures; representative
Sec. 6. (a) A health maintenance organization shall establishprocedures to assist enrollees and subscribers in filing grievances.
(b) An enrollee or subscriber may designate a representative tofile a grievance for the enrollee or subscriber and to represent theenrollee or subscriber in a grievance under this chapter.
As added by P.L.191-1997, SEC.8.
IC 27-13-10-7
Resolution of grievances
Sec. 7. (a) A health maintenance organization shall establishwritten policies and procedures for the timely resolution ofgrievances filed under this chapter. The policies and procedures mustinclude the following:
(1) An acknowledgment of the grievance, orally or in writing,to the enrollee or subscriber within three (3) business days.
(2) Documentation of the substance of the grievance and anyactions taken.
(3) An investigation of the substance of the grievance, includingany aspects involving clinical care.
(4) Notification to the enrollee or subscriber of the dispositionof the grievance and the right to appeal.
(5) Standards for timeliness in responding to complaints andproviding notice to enrollees and subscribers of the dispositionof the complaint and the right to appeal that accommodate theclinical urgency of the situation.
(b) The health maintenance organization shall appoint at least one(1) individual to resolve the complaint.
(c) A grievance must be resolved as expeditiously as possible, butnot more than twenty (20) business days after the grievance is filed.If a health maintenance organization is unable to make a decisionregarding the grievance within the twenty (20) day period due tocircumstances beyond the health maintenance organization's control,the health maintenance organization shall: (1) notify the enrollee or subscriber in writing of the reason forthe delay before the twentieth business day; and
(2) issue a written decision regarding the complaint within anadditional ten (10) business days.
(d) A health maintenance organization shall notify the enrollee orsubscriber in writing of the resolution of the grievance within five (5)business days after completing the investigation. The grievanceresolution notice must contain the following:
(1) The decision reached by the health maintenanceorganization.
(2) The reasons, policies, and procedures that are the basis ofthe decision.
(3) Notice of the enrollee's or subscriber's right to appeal thedecision.
(4) The department, address, and telephone number throughwhich an enrollee may contact a qualified representative toobtain more information about the decision or the right toappeal.
As added by P.L.191-1997, SEC.9.
IC 27-13-10-8
Appeals of grievance decisions; filing of report for violation
Sec. 8. (a) A health maintenance organization shall establishwritten policies and procedures for the timely resolution of appealsof grievance decisions. The procedures for registering andresponding to oral and written appeals of grievance decisions mustinclude the following:
(1) Acknowledgment of the appeal, orally or in writing, withinthree (3) business days after receipt of the appeal being filed.
(2) Documentation of the substance of the appeal and theactions taken.
(3) Investigation of the substance of the appeal, including anyaspects of clinical care involved.
(4) Notification to enrollees or subscribers of the disposition ofthe appeal and that the enrollee or subscriber may have the rightto further remedies allowed by law.
(5) Standards for timeliness in responding to appeals andproviding notice to enrollees or subscribers of the disposition ofthe appeal and the right to initiate an external appeals processthat accommodate the clinical urgency of the situation.
(b) The health maintenance organization shall appoint a panel ofqualified individuals to resolve an appeal. An individual may not beappointed to the panel who has been involved in the matter givingrise to the complaint or in the initial investigation of the complaint.Except for grievances that have previously been appealed underIC 27-8-17, in the case of an appeal from the proposal, refusal, ordelivery of a health care procedure, treatment, or service, the healthmaintenance organization shall appoint one (1) or more individualsto the panel to resolve the appeal. The panel must include one (1) ormore individuals who: (1) have knowledge in the medical condition, procedure, ortreatment at issue;
(2) are in the same licensed profession as the provider whoproposed, refused, or delivered the health care procedure,treatment, or service;
(3) are not involved in the matter giving rise to the appeal or theprevious grievance process; and
(4) do not have a direct business relationship with the enrolleeor the health care provider who previously recommended thehealth care procedure, treatment, or service giving rise to thegrievance.
(c) An appeal of a grievance decision must be resolved asexpeditiously as possible and with regard to the clinical urgency ofthe appeal. However, an appeal must be resolved not later thanforty-five (45) days after the appeal is filed. A health maintenanceorganization that violates this subsection commits an unfair anddeceptive act or practice in the business of insurance underIC 27-4-1-4.
(d) If a health maintenance organization violates subsection (c),the health maintenance organization shall file a report with thedepartment during the quarter in which the violation occurredconcerning the insurer's compliance with subsection (c). The reportmust include the following:
(1) The number of appealed grievance decisions that were notresolved as required under subsection (c).
(2) The reason each appeal described in subdivision (1) was notresolved.
(e) A health maintenance organization shall allow enrollees andsubscribers the opportunity to appear in person at the panel or tocommunicate with the panel through appropriate other means if theenrollee or subscriber is unable to appear in person.
(f) A health maintenance organization shall notify the enrollee orsubscriber in writing of the resolution of the appeal of a grievancewithin five (5) business days after completing the investigation. Thegrievance resolution notice must contain the following:
(1) The decision reached by the health maintenanceorganization.
(2) The reasons, policies, or procedures that are the basis of thedecision.
(3) Notice of the enrollee's or subscriber's right to furtherremedies allowed by law, including the right to review by anindependent review organization under IC 27-13-10.1.
(4) The department, address, and telephone number throughwhich an enrollee may contact a qualified representative toobtain more information about the decision or the right to anappeal.
As added by P.L.191-1997, SEC.10. Amended by P.L.133-1999,SEC.6; P.L.178-2003, SEC.85.
IC 27-13-10-9
Reserved
IC 27-13-10-10
Reserved
IC 27-13-10-11
Action against provider representing enrollee or subscriber
Sec. 11. A health maintenance organization may not take actionagainst a provider solely on the basis that the provider represents anenrollee or subscriber in a grievance filed under this chapter.
As added by P.L.191-1997, SEC.11.
IC 27-13-10-12
Approval of grievance and appeals procedures
Sec. 12. (a) Notwithstanding IC 27-13, the department shallapprove the grievance and appeals procedures of a healthmaintenance organization if:
(1) the health maintenance organization certifies in writing tothe department of the health maintenance organization'scompliance with grievance and appeals procedures establishedby the federal Centers for Medicare and Medicaid Services ofthe United States Department of Health and Human Services;and
(2) the department certifies that the grievance and appealsprocedures established by the federal Centers for Medicare andMedicaid Services of the United States Department of Healthand Human Services are substantially similar to the grievanceand appeals process in IC 27-13.
(b) Subsection (a) does not:
(1) limit the authority of the department;
(2) limit the responsibility of a health maintenanceorganization;
(3) release a health maintenance organization from theprohibitions established under section 11 of this chapter; or
(4) require a health maintenance organization to use a grievanceand appeals procedure established by the federal Centers forMedicare and Medicaid Services of the United StatesDepartment of Health and Human Services.
As added by P.L.191-1997, SEC.12. Amended by P.L.66-2002,SEC.17.
IC 27-13-10-13
Adoption of rules
Sec. 13. The department may adopt rules under IC 4-22-2 toimplement this chapter.
As added by P.L.191-1997, SEC.13.