CHAPTER 10.1. EXTERNAL REVIEW OF GRIEVANCES
IC 27-13-10.1
Chapter 10.1. External Review of Grievances
IC 27-13-10.1-1
External grievance procedure established
Sec. 1. A health maintenance organization shall establish andmaintain an external grievance procedure for the resolution ofgrievances regarding:
(1) an adverse utilization review determination (as defined inIC 27-8-17-8);
(2) an adverse determination of medical necessity; or
(3) a determination that a proposed service is experimental orinvestigational;
made by a health maintenance organization or an agent of a healthmaintenance organization regarding a service proposed by thetreating physician.
As added by P.L.133-1999, SEC.7.
IC 27-13-10.1-2
Requirements of procedure
Sec. 2. (a) An external grievance procedure established undersection 1 of this chapter must:
(1) allow an enrollee or the enrollee's representative to file awritten request with the health maintenance organization for anappeal of the health maintenance organization's grievanceresolution under IC 27-13-10-8 not later than forty-five (45)days after the enrollee is notified of the resolution underIC 27-13-10-8; and
(2) provide for:
(A) an expedited appeal for a grievance related to an illness,a disease, a condition, an injury, or a disability that wouldseriously jeopardize the enrollee's:
(i) life or health; or
(ii) ability to reach and maintain maximum function; or
(B) a standard appeal for a grievance not described in clause(A).
An enrollee may file not more than one (1) appeal of a healthmaintenance organization's grievance resolution under this chapter.
(b) Subject to the requirements of subsection (d), when a requestis filed under subsection (a), the health maintenance organizationshall:
(1) select a different independent review organization for eachappeal filed under this chapter from the list of independentreview organizations that are certified by the department undersection 8 of this chapter; and
(2) rotate the choice of an independent review organizationamong all certified independent review organizations beforerepeating a selection.
(c) The independent review organizations shall assign a medicalreview professional who is board certified in the applicable specialty
for resolution of an appeal.
(d) The independent review organization and the medical reviewprofessional conducting the external review under this chapter maynot have a material professional, familial, financial, or otheraffiliation with any of the following:
(1) The health maintenance organization.
(2) Any officer, director, or management employee of the healthmaintenance organization.
(3) The physician or the physician's medical group that isproposing the service.
(4) The facility at which the service would be provided.
(5) The development or manufacture of the principal drug,device, procedure, or other therapy that is proposed by thetreating physician.
However, the medical review professional may have an affiliationunder which the medical review professional provides health careservices to enrollees of the health maintenance organization and mayhave an affiliation that is limited to staff privileges at the healthfacility if the affiliation is disclosed to the enrollee and the healthmaintenance organization before commencing the review and neitherthe enrollee nor the health maintenance organization objects.
(e) The enrollee may be required to pay not more than twenty-fivedollars ($25) of the costs associated with the services of anindependent review organization under this chapter. All additionalcosts must be paid by the health maintenance organization.
As added by P.L.133-1999, SEC.7.
IC 27-13-10.1-3
Cooperation with review organization; requirements of enrollee
Sec. 3. (a) An enrollee who files an appeal under this chaptershall:
(1) not be subject to retaliation for exercising the enrollee'sright to an appeal under this chapter;
(2) be permitted to utilize the assistance of other individuals,including physicians, attorneys, friends, and family membersthroughout the review process;
(3) be permitted to submit additional information relating to theproposed service throughout the review process; and
(4) cooperate with the independent review organization by:
(A) providing any requested medical information; or
(B) authorizing the release of necessary medical information.
(b) A health maintenance organization shall cooperate with anindependent review organization selected under section 2 of thischapter by promptly providing any information requested by theindependent review organization.
As added by P.L.133-1999, SEC.7.
IC 27-13-10.1-4
Requirements of independent review organization
Sec. 4. (a) An independent review organization shall: (1) for an expedited appeal filed under section 2(a)(2)(A) of thischapter, within seventy-two (72) hours after the appeal is filed;or
(2) for a standard appeal filed under section 2(a)(2)(B) of thischapter, within fifteen (15) business days after the appeal isfiled;
make a determination to uphold or reverse the health maintenanceorganization's grievance resolution under IC 27-13-10-8 based oninformation gathered from the enrollee or the enrollee's designee, thehealth maintenance organization, and the treating physician, and anyadditional information that the independent review organizationconsiders necessary and appropriate.
(b) When making the determination under this section, theindependent review organization shall apply:
(1) standards of decision making that are based on objectiveclinical evidence; and
(2) the terms of the enrollee's benefit contract.
(c) The independent review organization shall notify the healthmaintenance organization and the enrollee of the determination madeunder this section:
(1) for an expedited appeal filed under section 2(a)(2)(A) of thischapter, within twenty-four (24) hours after making thedetermination; or
(2) for a standard appeal filed under section 2(a)(2)(B) of thischapter, within seventy-two (72) hours after making thedetermination.
As added by P.L.133-1999, SEC.7.
IC 27-13-10.1-4.5
Information from independent review organization
Sec. 4.5. Upon the request of an enrollee who is notified undersection 4(c) of this chapter that the independent review organizationhas made a determination, the independent review organization shallprovide to the enrollee all information reasonably necessary toenable the enrollee to understand the:
(1) effect of the determination on the enrollee; and
(2) manner in which the health maintenance organization maybe expected to respond to the determination.
As added by P.L.173-2007, SEC.43.
IC 27-13-10.1-5
Determination binding on health maintenance organization
Sec. 5. A determination made under section 4 of this chapter isbinding on the health maintenance organization.
As added by P.L.133-1999, SEC.7.
IC 27-13-10.1-6
Reconsideration of resolution
Sec. 6. (a) If at any time during an external review performedunder this chapter, the enrollee submits information to the health
maintenance organization that is relevant to the health maintenanceorganization's resolution under IC 27-13-10-8 and was not consideredby the health maintenance organization under IC 27-13-10:
(1) the health maintenance organization shall reconsider thehealth maintenance organization's resolution underIC 27-13-10-8; and
(2) the independent review organization shall cease the externalreview process until the reconsideration under subsection (b) iscompleted.
(b) A health maintenance organization to which information issubmitted under subsection (a) shall reconsider the resolution underIC 27-13-10-8 based on the information and notify the enrollee of thehealth maintenance organization's decision:
(1) within seventy-two (72) hours after the information issubmitted for a reconsideration related to an illness, a disease,a condition, an injury, or a disability that would seriouslyjeopardize the enrollee's:
(A) life or health; or
(B) ability to reach and maintain maximum function; or
(2) within fifteen (15) days after the information is submittedfor a reconsideration not described in subdivision (1).
(c) If the decision reached under subsection (b) is adverse to theenrollee, the enrollee may request that the independent revieworganization resume the external review under this chapter.
As added by P.L.133-1999, SEC.7.
IC 27-13-10.1-7
Terms of coverage unchanged
Sec. 7. This chapter does not add to or otherwise change the termsof coverage included in a contract under which an enrollee receiveshealth care benefits under IC 27-13.
As added by P.L.133-1999, SEC.7.
IC 27-13-10.1-8
Certification of independent review organizations
Sec. 8. (a) The department shall establish and maintain a processfor annual certification of independent review organizations.
(b) The department shall certify a number of independent revieworganizations determined by the department to be sufficient to fulfillthe purposes of this chapter.
(c) An independent review organization shall meet the followingminimum requirements for certification by the department:
(1) Medical review professionals assigned by the independentreview organization to perform external grievance reviewsunder this chapter:
(A) must be board certified in the specialty in which anenrollee's proposed service would be provided;
(B) must be knowledgeable about a proposed servicethrough 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 sanctionsincluding:
(i) loss of staff privileges; or
(ii) restriction on participation;
taken or pending by any hospital, government, or regulatorybody.
(2) The independent review organization must have a qualityassurance mechanism to ensure the:
(A) timeliness and quality of reviews;
(B) qualifications and independence of medical reviewprofessionals;
(C) confidentiality of medical records and other reviewmaterials; and
(D) satisfaction of enrollees with the procedures utilized bythe independent review organization, including the use ofenrollee satisfaction surveys.
(3) The independent review organization must file with thedepartment the following information before March 1 of eachyear:
(A) The number and percentage of determinations made infavor of enrollees.
(B) The number and percentage of determinations made infavor of health maintenance organizations.
(C) The average time to process a determination.
(D) Any other information required by the department.
The information required under this subdivision must bespecified for each health maintenance organization for whichthe independent review organization performed reviews duringthe reporting year.
(4) Any additional requirements established by the department.
(d) The department may not certify an independent revieworganization that is one (1) of the following:
(1) A professional or trade association of health care providersor a subsidiary or an affiliate of a professional or tradeassociation of health care providers.
(2) A health insurer, health maintenance organization, or healthplan association or a subsidiary or an affiliate of a healthinsurer, health maintenance organization, or health planassociation.
(e) The department may suspend or revoke an independent revieworganization's certification if the department finds that theindependent review organization is not in substantial compliancewith the certification requirements under this section.
(f) The department shall make available to health maintenanceorganizations a list of all certified independent review organizations.
(g) The department shall make the information provided to thedepartment under subsection (c)(3) available to the public in a formatthat does not identify individual enrollees.
As added by P.L.133-1999, SEC.7. Amended by P.L.14-2000,
SEC.60.
IC 27-13-10.1-9
Confidentiality
Sec. 9. Except as provided in section 8(g) of this chapter,documents and other information created or received by theindependent review organization or the medical review professionalin connection with an external review under this chapter:
(1) are not public records;
(2) may not be disclosed under IC 5-14-3; and
(3) must be treated in accordance with confidentialityrequirements of state and federal law.
As added by P.L.133-1999, SEC.7.
IC 27-13-10.1-10
Immunity from civil liability
Sec. 10. (a) An independent review organization is immune fromcivil liability for actions taken in good faith in connection with anexternal review under this chapter.
(b) The work product or determination, or both, of an independentreview organization under this chapter are admissible in a judicial oradministrative proceeding. However, the work product ordetermination, or both, do not, without other supporting evidence,satisfy any party's burden of proof or persuasion concerning anymaterial issue of fact or law.
As added by P.L.133-1999, SEC.7.
IC 27-13-10.1-11
Medicare review
Sec. 11. If an enrollee has the right to an external review underMedicare (42 U.S.C. 1395 et seq.) the enrollee may not request anexternal review under this chapter.
As added by P.L.133-1999, SEC.7.
IC 27-13-10.1-12
Adoption of rules
Sec. 12. The department may adopt rules under IC 4-22-2 toimplement this chapter.
As added by P.L.133-1999, SEC.7.