CHAPTER 29. EXTERNAL REVIEW OF GRIEVANCES
IC 27-8-29
Chapter 29. External Review of Grievances
IC 27-8-29-1
"Accident and sickness insurance policy" defined
Sec. 1. As used in this chapter, "accident and sickness insurancepolicy" has the meaning set forth in IC 27-8-28-1.
As added by P.L.66-2001, SEC.3 and P.L.203-2001, SEC.14.
IC 27-8-29-2
"Appeal" defined
Sec. 2. As used in this chapter, "appeal" means the proceduredescribed in IC 27-8-28-17.
As added by P.L.66-2001, SEC.3 and P.L.203-2001, SEC.14.
IC 27-8-29-3
"Commissioner" defined
Sec. 3. As used in this chapter, "commissioner" refers to theinsurance commissioner appointed under IC 27-1-1-2.
As added by P.L.66-2001, SEC.3 and P.L.203-2001, SEC.14.Amended by P.L.1-2002, SEC.117.
IC 27-8-29-4
"Covered individual" defined
Sec. 4. As used in this chapter, "covered individual" has themeaning set forth in IC 27-8-28-3.
As added by P.L.66-2001, SEC.3 and P.L.203-2001, SEC.14.
IC 27-8-29-5
"Department" defined
Sec. 5. As used in this chapter, "department" refers to thedepartment of insurance.
As added by P.L.66-2001, SEC.3 and P.L.203-2001, SEC.14.
IC 27-8-29-6
"External grievance" defined
Sec. 6. As used in this chapter, "external grievance" means theindependent review under this chapter of a:
(1) grievance filed under IC 27-8-28; or
(2) denial of coverage based on a waiver described inIC 27-8-5-2.5(e) (expired July 1, 2007, and removed) orIC 27-8-5-19.2 (expired July 1, 2007, and repealed).
As added by P.L.66-2001, SEC.3 and P.L.203-2001, SEC.14.Amended by P.L.211-2003, SEC.6; P.L.3-2008, SEC.215.
IC 27-8-29-7
"Grievance" defined
Sec. 7. As used in this chapter, "grievance" has the meaning setforth in IC 27-8-28-6.
As added by P.L.66-2001, SEC.3 and P.L.203-2001, SEC.14.
IC 27-8-29-8
"Grievance procedure" defined
Sec. 8. As used in this chapter, "grievance procedure" has themeaning set forth in IC 27-8-28-7.
As added by P.L.66-2001, SEC.3 and P.L.203-2001, SEC.14.
IC 27-8-29-9
"Health care provider" defined
Sec. 9. As used in this chapter, "health care provider" means aperson:
(1) that provides physician services (as defined inIC 12-15-11-1(a)); or
(2) who is licensed under IC 25-33.
As added by P.L.66-2001, SEC.3 and P.L.203-2001, SEC.14.
IC 27-8-29-10
"Insured" defined
Sec. 10. As used in this chapter, "insured" has the meaning setforth in IC 27-8-28-8.
As added by P.L.66-2001, SEC.3 and P.L.203-2001, SEC.14.
IC 27-8-29-11
"Insurer" defined
Sec. 11. As used in this chapter, "insurer" has the meaning setforth in IC 27-8-28-9.
As added by P.L.66-2001, SEC.3 and P.L.203-2001, SEC.14.
IC 27-8-29-12
Insurer to establish external grievance procedures
Sec. 12. An insurer shall establish and maintain an externalgrievance procedure for the resolution of external grievancesregarding:
(1) an adverse determination of appropriateness;
(2) an adverse determination of medical necessity;
(3) a determination that a proposed service is experimental orinvestigational; or
(4) a denial of coverage based on a waiver described inIC 27-8-5-2.5(e) (expired July 1, 2007, and removed) orIC 27-8-5-19.2 (expired July 1, 2007, and repealed);
made by an insurer or an agent of an insurer regarding a serviceproposed by the treating health care provider.
As added by P.L.66-2001, SEC.3 and P.L.203-2001, SEC.14.Amended by P.L.211-2003, SEC.7; P.L.3-2008, SEC.216.
IC 27-8-29-13
Requirements for external grievance procedure; independentreview organizations
Sec. 13. (a) An external grievance procedure established undersection 12 of this chapter must:
(1) allow a covered individual or a covered individual's
representative to file a written request with the insurer for anexternal grievance review of the insurer's:
(A) appeal resolution under IC 27-8-28-17; or
(B) denial of coverage based on a waiver described inIC 27-8-5-2.5(e) (expired July 1, 2007, and removed) orIC 27-8-5-19.2 (expired July 1, 2007, and repealed);
not more than forty-five (45) days after the covered individualis notified of the resolution; and
(2) provide for:
(A) an expedited external grievance review for a grievancerelated to an illness, a disease, a condition, an injury, or adisability if the time frame for a standard review wouldseriously jeopardize the covered individual's:
(i) life or health; or
(ii) ability to reach and maintain maximum function; or
(B) a standard external grievance review for a grievance notdescribed in clause (A).
A covered individual may file not more than one (1) externalgrievance of an insurer's appeal resolution under this chapter.
(b) Subject to the requirements of subsection (d), when a requestis filed under subsection (a), the insurer shall:
(1) select a different independent review organization for eachexternal grievance filed under this chapter from the list ofindependent review organizations that are certified by thedepartment under section 19 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 organization chosen under subsection(b) shall assign a medical review professional who is board certifiedin the applicable specialty for resolution of an external grievance.
(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 insurer.
(2) Any officer, director, or management employee of theinsurer.
(3) The health care provider or the health care provider'smedical group that is proposing 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 for use bythe treating health care provider.
(6) The covered individual requesting the external grievancereview.
However, the medical review professional may have an affiliationunder which the medical review professional provides health careservices to covered individuals of the insurer and may have anaffiliation that is limited to staff privileges at the health facility, if the
affiliation is disclosed to the covered individual and the insurerbefore commencing the review and neither the covered individualnor the insurer objects.
(e) A covered individual shall not pay any of the costs associatedwith the services of an independent review organization under thischapter. All costs must be paid by the insurer.
As added by P.L.66-2001, SEC.3 and P.L.203-2001, SEC.14.Amended by P.L.1-2002, SEC.118; P.L.211-2003, SEC.8;P.L.3-2008, SEC.217.
IC 27-8-29-14
Rights of individuals who file grievances
Sec. 14. (a) A covered individual who files an external grievanceunder this chapter:
(1) shall not be subject to retaliation for exercising the coveredindividual's right to an external grievance under this chapter;
(2) shall be permitted to utilize the assistance of otherindividuals, including health care providers, attorneys, friends,and family members throughout the review process;
(3) shall be permitted to submit additional information relatingto the proposed service throughout the review process; and
(4) shall cooperate with the independent review organizationby:
(A) providing any requested medical information; or
(B) authorizing the release of necessary medical information.
(b) An insurer shall cooperate with an independent revieworganization selected under section 13(b) of this chapter by promptlyproviding any information requested by the independent revieworganization.
As added by P.L.66-2001, SEC.3 and P.L.203-2001, SEC.14.Amended by P.L.1-2002, SEC.119.
IC 27-8-29-15
Independent review organizations; determinations
Sec. 15. (a) An independent review organization shall:
(1) for an expedited external grievance filed under section13(a)(2)(A) of this chapter, within three (3) business days afterthe external grievance is filed; or
(2) for a standard appeal filed under section 13(a)(2)(B) of thischapter, within fifteen (15) business days after the appeal isfiled;
make a determination to uphold or reverse the insurer's appealresolution under IC 27-8-28-17 based on information gathered fromthe covered individual or the covered individual's designee, theinsurer, and the treating health care provider, and any additionalinformation that the independent review organization considersnecessary and appropriate.
(b) When making the determination under this section, theindependent 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 sicknessinsurance policy.
(c) In an external grievance described in section 12(4) of thischapter, the insurer bears the burden of proving that the insurerproperly denied coverage for a condition, complication, service, ortreatment because the condition, complication, service, or treatmentis directly related to a condition for which coverage has been waivedunder IC 27-8-5-2.5(e) (expired July 1, 2007, and removed) orIC 27-8-5-19.2 (expired July 1, 2007, and repealed).
(d) The independent review organization shall notify the insurerand the covered individual of the determination made under thissection:
(1) for an expedited external grievance filed under section13(a)(2)(A) of this chapter, within twenty-four (24) hours aftermaking the determination; and
(2) for a standard external grievance filed under section13(a)(2)(B) of this chapter, within seventy-two (72) hours aftermaking the determination.
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.
IC 27-8-29-15.5
Information from independent review organization
Sec. 15.5. Upon the request of a covered individual who isnotified under section 15(d) of this chapter that the independentreview organization has made a determination, the independentreview organization shall provide to the covered individual allinformation reasonably necessary to enable the covered individual tounderstand the:
(1) effect of the determination on the covered individual; and
(2) manner in which the insurer may be expected to respond tothe determination.
As added by P.L.173-2007, SEC.42.
IC 27-8-29-16
Binding determinations
Sec. 16. A determination made under section 15 of this chapter isbinding on the insurer.
As added by P.L.66-2001, SEC.3 and P.L.203-2001, SEC.14.
IC 27-8-29-17
Reconsideration of resolution by insurer
Sec. 17. (a) If, at any time during an external review performedunder this chapter, the covered individual submits information to theinsurer that is relevant to the insurer's resolution of the coveredindividual's appeal of a grievance decision under IC 27-8-28-17 andthat was not considered by the insurer under IC 27-8-28:
(1) the insurer may reconsider the resolution underIC 27-8-28-17; and (2) if the insurer chooses to reconsider, the independent revieworganization shall cease the external review process until thereconsideration under subsection (b) is completed.
(b) An insurer reconsidering the resolution of an appeal of agrievance decision due to the submission of information undersubsection (a) shall reconsider the resolution under IC 27-8-28-17based on the information and notify the covered individual of theinsurer'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 covered individual's:
(A) life or health; or
(B) ability to reach and maintain maximum function; or
(2) within fifteen (15) days after the information is submitted,for a reconsideration not described in subdivision (1).
(c) If the decision reached under subsection (b) is adverse to thecovered individual, the covered individual may request that theindependent review organization resume the external review underthis chapter.
(d) If an insurer to which information is submitted undersubsection (a) chooses not to reconsider the insurer's resolution underIC 27-8-28-17, the insurer shall forward the submitted informationto the independent review organization not more than two (2)business days after the insurer's receipt of the information.
As added by P.L.66-2001, SEC.3 and P.L.203-2001, SEC.14.Amended by P.L.1-2002, SEC.120.
IC 27-8-29-18
Applicability of chapter
Sec. 18. This chapter does not add to or otherwise change theterms of coverage included in a policy, certificate, or contract underwhich a covered individual receives health care benefits underIC 27-8.
As added by P.L.66-2001, SEC.3 and P.L.203-2001, SEC.14.
IC 27-8-29-19
Annual certifications of independent review organizations
Sec. 19. (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 must 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 acovered individual'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 ofthe United States; and
(D) must not have any history of disciplinary actions orsanctions, including:
(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:
(A) the timeliness and quality of reviews;
(B) the qualifications and independence of medical reviewprofessionals;
(C) the confidentiality of medical records and other reviewmaterials; and
(D) the satisfaction of covered individuals with theprocedures utilized by the independent review organization,including the use of covered individual satisfaction surveys.
(3) The independent review organization must file with thedepartment the following information on or before March 1 ofeach year:
(A) The number and percentage of determinations made infavor of covered individuals.
(B) The number and percentage of determinations made infavor of insurers.
(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 insurer for which the independent revieworganization performed reviews during the 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) An insurer, a health maintenance organization, or a healthplan association, or a subsidiary or an affiliate of an insurer,health maintenance organization, or health plan association.
(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 insurers a list of allcertified 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 covered individuals.As added by P.L.66-2001, SEC.3 and P.L.203-2001, SEC.14.Amended by P.L.1-2002, SEC.121.
IC 27-8-29-20
Documents of review organizations
Sec. 20. Except as provided in section 19(g) of this chapter,documents and other information created or received by theindependent review organization or the medical review professionalin connection with an external grievance 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.66-2001, SEC.3 and P.L.203-2001, SEC.14.
IC 27-8-29-21
Filing description of grievance procedure
Sec. 21. (a) An insurer shall each year file with the commissionera description of the grievance procedure established by the insurerunder this chapter, including:
(1) the total number of external grievances handled through theprocedure during the preceding calendar year;
(2) a compilation of the causes underlying those grievances; and
(3) a summary of the final disposition of those grievances;
for each independent review organization used by the insurer duringthe reporting year.
(b) The information required by subsection (a) must be filed withthe commissioner on or before March 1 of each year. Thecommissioner shall:
(1) make the information required to be filed under this sectionavailable to the public; and
(2) prepare an annual compilation of the data required undersubsection (a) that allows for comparative analysis.
(c) The commissioner may require any additional reports that arenecessary and appropriate for the commissioner to carry out thecommissioner's duties under this article.
As added by P.L.66-2001, SEC.3 and P.L.203-2001, SEC.14.Amended by P.L.1-2002, SEC.122.
IC 27-8-29-22
Immunity from civil liability; work product or determination
Sec. 22. (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 a party's burden of proof or persuasion concerning anymaterial issue of fact or law.As added by P.L.66-2001, SEC.3 and P.L.203-2001, SEC.14.
IC 27-8-29-23
Medicare
Sec. 23. If a covered individual has the right to an external reviewof a grievance under Medicare, the covered individual may notrequest an external review of the same grievance under this chapter.
As added by P.L.66-2001, SEC.3 and P.L.203-2001, SEC.14.
IC 27-8-29-24
Rules
Sec. 24. The department may adopt rules under IC 4-22-2 toimplement this chapter.
As added by P.L.66-2001, SEC.3 and P.L.203-2001, SEC.14.