IC 27-13-10-1 Establishment of procedures
Sec. 1. A health maintenance organization or limited service
health maintenance organization shall establish and maintain a
grievance procedure for the resolution of grievances initiated by
enrollees and subscribers of the organization. The grievance
procedure of a health maintenance organization or limited service
health maintenance organization must be approved by the
commissioner. 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 procedures
of health maintenance organizations and limited service health
maintenance 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 service
health maintenance organization shall maintain records regarding all
grievances of enrollees that the organization has received since the
examination by the commissioner of the grievance procedure of the
organization 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 provide
timely, adequate, and appropriate notice to each enrollee or
subscriber of the grievance procedure under this chapter and
IC 27-13-10.1.
(b) A health maintenance organization shall prominently display
on all notices to enrollees and subscribers the telephone number and
address at which a grievance may be filed.
(c) A written description of the enrollee's or subscriber's right to
file a grievance must be posted by the provider in a conspicuous
public location in each facility that offers services on behalf of a
health 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 orally
or in writing.
(b) A health maintenance organization shall make available to
enrollees and subscribers a toll free telephone number through which
grievances may be filed. The toll free number must:
(1) be staffed by a qualified representative of the health
maintenance organization;
(2) be available for at least forty (40) normal business hours per
week; and
(3) accept grievances in the languages of the major population
groups served.
(c) A grievance is considered to be filed on the first date it is
received, 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 establish
procedures to assist enrollees and subscribers in filing grievances.
(b) An enrollee or subscriber may designate a representative to
file a grievance for the enrollee or subscriber and to represent the
enrollee 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 establish
written policies and procedures for the timely resolution of
grievances filed under this chapter. The policies and procedures must
include 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 any
actions taken.
(3) An investigation of the substance of the grievance, including
any aspects involving clinical care.
(4) Notification to the enrollee or subscriber of the disposition
of the grievance and the right to appeal.
(5) Standards for timeliness in responding to complaints and
providing notice to enrollees and subscribers of the disposition
of the complaint and the right to appeal that accommodate the
clinical 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, but
not more than twenty (20) business days after the grievance is filed.
If a health maintenance organization is unable to make a decision
regarding the grievance within the twenty (20) day period due to
circumstances beyond the health maintenance organization's control,
the health maintenance organization shall:
(1) notify the enrollee or subscriber in writing of the reason for
the delay before the twentieth business day; and
(2) issue a written decision regarding the complaint within an
additional ten (10) business days.
(d) A health maintenance organization shall notify the enrollee or
subscriber in writing of the resolution of the grievance within five (5)
business days after completing the investigation. The grievance
resolution notice must contain the following:
(1) The decision reached by the health maintenance
organization.
(2) The reasons, policies, and procedures that are the basis of
the decision.
(3) Notice of the enrollee's or subscriber's right to appeal the
decision.
(4) The department, address, and telephone number through
which an enrollee may contact a qualified representative to
obtain more information about the decision or the right to
appeal. 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 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) Acknowledgment of the appeal, orally or in writing, within
three (3) business days after receipt of the appeal being 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 enrollees or subscribers of the disposition of
the appeal and that the enrollee or subscriber may have the right
to further remedies allowed by law.
(5) Standards for timeliness in responding to appeals and
providing notice to enrollees or subscribers of the disposition of
the appeal and the right to initiate an external appeals process
that accommodate the clinical urgency of the situation.
(b) The health maintenance organization shall appoint a panel of
qualified individuals to resolve an appeal. An individual may not be
appointed to the panel who has been involved in the matter giving
rise to the complaint or in the initial investigation of the complaint.
Except for grievances that have previously been appealed under
IC 27-8-17, in the case of an appeal from the proposal, refusal, or
delivery of a health care procedure, treatment, or service, the health
maintenance organization shall appoint one (1) or more individuals
to the panel to resolve the appeal. The panel must include one (1) or
more individuals who:
(1) have knowledge in the medical condition, procedure, or
treatment at issue;
(2) are in the same licensed profession as the provider who
proposed, refused, or delivered the health care procedure,
treatment, or service;
(3) are not involved in the matter giving rise to the appeal or the
previous grievance process; and
(4) do not have a direct business relationship with the enrollee
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 as
expeditiously as possible and with regard to the clinical urgency of
the appeal. However, an appeal must be resolved not later than
forty-five (45) days after the appeal is filed. A health maintenance
organization 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 a health maintenance organization violates subsection (c),
the health maintenance organization 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) A health maintenance organization shall allow enrollees and
subscribers the opportunity to appear in person at the panel or to
communicate with the panel through appropriate other means if the
enrollee or subscriber is unable to appear in person.
(f) A health maintenance organization shall notify the enrollee or
subscriber in writing of the resolution of the appeal of a grievance
within five (5) business days after completing the investigation. The
grievance resolution notice must contain the following:
(1) The decision reached by the health maintenance
organization.
(2) The reasons, policies, or procedures that are the basis of the
decision.
(3) Notice of the enrollee's or subscriber's right to further
remedies allowed by law, including the right to review by an
independent review organization under IC 27-13-10.1.
(4) The department, address, and telephone number through
which an enrollee may contact a qualified representative to
obtain more information about the decision or the right to an
appeal. 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 action
against a provider solely on the basis that the provider represents an
enrollee 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 shall
approve the grievance and appeals procedures of a health
maintenance organization if:
(1) the health maintenance organization certifies in writing to
the department of the health maintenance organization's
compliance with grievance and appeals procedures established
by the federal Centers for Medicare and Medicaid Services of
the United States Department of Health and Human Services;
and
(2) the department certifies that the grievance and appeals
procedures established by the federal Centers for Medicare and
Medicaid Services of the United States Department of Health
and Human Services are substantially similar to the grievance
and 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 maintenance
organization;
(3) release a health maintenance organization from the
prohibitions established under section 11 of this chapter; or
(4) require a health maintenance organization to use a grievance
and appeals procedure established by the federal Centers for
Medicare and Medicaid Services of the United States
Department 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 to
implement this chapter. As added by P.L.191-1997, SEC.13.
IC 27-13-10-1 Establishment of procedures
Sec. 1. A health maintenance organization or limited service
health maintenance organization shall establish and maintain a
grievance procedure for the resolution of grievances initiated by
enrollees and subscribers of the organization. The grievance
procedure of a health maintenance organization or limited service
health maintenance organization must be approved by the
commissioner. 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 procedures
of health maintenance organizations and limited service health
maintenance 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 service
health maintenance organization shall maintain records regarding all
grievances of enrollees that the organization has received since the
examination by the commissioner of the grievance procedure of the
organization 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 provide
timely, adequate, and appropriate notice to each enrollee or
subscriber of the grievance procedure under this chapter and
IC 27-13-10.1.
(b) A health maintenance organization shall prominently display
on all notices to enrollees and subscribers the telephone number and
address at which a grievance may be filed.
(c) A written description of the enrollee's or subscriber's right to
file a grievance must be posted by the provider in a conspicuous
public location in each facility that offers services on behalf of a
health 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 orally
or in writing.
(b) A health maintenance organization shall make available to
enrollees and subscribers a toll free telephone number through which
grievances may be filed. The toll free number must:
(1) be staffed by a qualified representative of the health
maintenance organization;
(2) be available for at least forty (40) normal business hours per
week; and
(3) accept grievances in the languages of the major population
groups served.
(c) A grievance is considered to be filed on the first date it is
received, 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 establish
procedures to assist enrollees and subscribers in filing grievances.
(b) An enrollee or subscriber may designate a representative to
file a grievance for the enrollee or subscriber and to represent the
enrollee 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 establish
written policies and procedures for the timely resolution of
grievances filed under this chapter. The policies and procedures must
include 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 any
actions taken.
(3) An investigation of the substance of the grievance, including
any aspects involving clinical care.
(4) Notification to the enrollee or subscriber of the disposition
of the grievance and the right to appeal.
(5) Standards for timeliness in responding to complaints and
providing notice to enrollees and subscribers of the disposition
of the complaint and the right to appeal that accommodate the
clinical 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, but
not more than twenty (20) business days after the grievance is filed.
If a health maintenance organization is unable to make a decision
regarding the grievance within the twenty (20) day period due to
circumstances beyond the health maintenance organization's control,
the health maintenance organization shall:
(1) notify the enrollee or subscriber in writing of the reason for
the delay before the twentieth business day; and
(2) issue a written decision regarding the complaint within an
additional ten (10) business days.
(d) A health maintenance organization shall notify the enrollee or
subscriber in writing of the resolution of the grievance within five (5)
business days after completing the investigation. The grievance
resolution notice must contain the following:
(1) The decision reached by the health maintenance
organization.
(2) The reasons, policies, and procedures that are the basis of
the decision.
(3) Notice of the enrollee's or subscriber's right to appeal the
decision.
(4) The department, address, and telephone number through
which an enrollee may contact a qualified representative to
obtain more information about the decision or the right to
appeal. 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 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) Acknowledgment of the appeal, orally or in writing, within
three (3) business days after receipt of the appeal being 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 enrollees or subscribers of the disposition of
the appeal and that the enrollee or subscriber may have the right
to further remedies allowed by law.
(5) Standards for timeliness in responding to appeals and
providing notice to enrollees or subscribers of the disposition of
the appeal and the right to initiate an external appeals process
that accommodate the clinical urgency of the situation.
(b) The health maintenance organization shall appoint a panel of
qualified individuals to resolve an appeal. An individual may not be
appointed to the panel who has been involved in the matter giving
rise to the complaint or in the initial investigation of the complaint.
Except for grievances that have previously been appealed under
IC 27-8-17, in the case of an appeal from the proposal, refusal, or
delivery of a health care procedure, treatment, or service, the health
maintenance organization shall appoint one (1) or more individuals
to the panel to resolve the appeal. The panel must include one (1) or
more individuals who:
(1) have knowledge in the medical condition, procedure, or
treatment at issue;
(2) are in the same licensed profession as the provider who
proposed, refused, or delivered the health care procedure,
treatment, or service;
(3) are not involved in the matter giving rise to the appeal or the
previous grievance process; and
(4) do not have a direct business relationship with the enrollee
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 as
expeditiously as possible and with regard to the clinical urgency of
the appeal. However, an appeal must be resolved not later than
forty-five (45) days after the appeal is filed. A health maintenance
organization 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 a health maintenance organization violates subsection (c),
the health maintenance organization 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) A health maintenance organization shall allow enrollees and
subscribers the opportunity to appear in person at the panel or to
communicate with the panel through appropriate other means if the
enrollee or subscriber is unable to appear in person.
(f) A health maintenance organization shall notify the enrollee or
subscriber in writing of the resolution of the appeal of a grievance
within five (5) business days after completing the investigation. The
grievance resolution notice must contain the following:
(1) The decision reached by the health maintenance
organization.
(2) The reasons, policies, or procedures that are the basis of the
decision.
(3) Notice of the enrollee's or subscriber's right to further
remedies allowed by law, including the right to review by an
independent review organization under IC 27-13-10.1.
(4) The department, address, and telephone number through
which an enrollee may contact a qualified representative to
obtain more information about the decision or the right to an
appeal. 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 action
against a provider solely on the basis that the provider represents an
enrollee 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 shall
approve the grievance and appeals procedures of a health
maintenance organization if:
(1) the health maintenance organization certifies in writing to
the department of the health maintenance organization's
compliance with grievance and appeals procedures established
by the federal Centers for Medicare and Medicaid Services of
the United States Department of Health and Human Services;
and
(2) the department certifies that the grievance and appeals
procedures established by the federal Centers for Medicare and
Medicaid Services of the United States Department of Health
and Human Services are substantially similar to the grievance
and 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 maintenance
organization;
(3) release a health maintenance organization from the
prohibitions established under section 11 of this chapter; or
(4) require a health maintenance organization to use a grievance
and appeals procedure established by the federal Centers for
Medicare and Medicaid Services of the United States
Department 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 to
implement this chapter. As added by P.L.191-1997, SEC.13.
IC 27-13-10-1 Establishment of procedures
Sec. 1. A health maintenance organization or limited service
health maintenance organization shall establish and maintain a
grievance procedure for the resolution of grievances initiated by
enrollees and subscribers of the organization. The grievance
procedure of a health maintenance organization or limited service
health maintenance organization must be approved by the
commissioner. 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 procedures
of health maintenance organizations and limited service health
maintenance 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 service
health maintenance organization shall maintain records regarding all
grievances of enrollees that the organization has received since the
examination by the commissioner of the grievance procedure of the
organization 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 provide
timely, adequate, and appropriate notice to each enrollee or
subscriber of the grievance procedure under this chapter and
IC 27-13-10.1.
(b) A health maintenance organization shall prominently display
on all notices to enrollees and subscribers the telephone number and
address at which a grievance may be filed.
(c) A written description of the enrollee's or subscriber's right to
file a grievance must be posted by the provider in a conspicuous
public location in each facility that offers services on behalf of a
health 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 orally
or in writing.
(b) A health maintenance organization shall make available to
enrollees and subscribers a toll free telephone number through which
grievances may be filed. The toll free number must:
(1) be staffed by a qualified representative of the health
maintenance organization;
(2) be available for at least forty (40) normal business hours per
week; and
(3) accept grievances in the languages of the major population
groups served.
(c) A grievance is considered to be filed on the first date it is
received, 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 establish
procedures to assist enrollees and subscribers in filing grievances.
(b) An enrollee or subscriber may designate a representative to
file a grievance for the enrollee or subscriber and to represent the
enrollee 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 establish
written policies and procedures for the timely resolution of
grievances filed under this chapter. The policies and procedures must
include 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 any
actions taken.
(3) An investigation of the substance of the grievance, including
any aspects involving clinical care.
(4) Notification to the enrollee or subscriber of the disposition
of the grievance and the right to appeal.
(5) Standards for timeliness in responding to complaints and
providing notice to enrollees and subscribers of the disposition
of the complaint and the right to appeal that accommodate the
clinical 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, but
not more than twenty (20) business days after the grievance is filed.
If a health maintenance organization is unable to make a decision
regarding the grievance within the twenty (20) day period due to
circumstances beyond the health maintenance organization's control,
the health maintenance organization shall:
(1) notify the enrollee or subscriber in writing of the reason for
the delay before the twentieth business day; and
(2) issue a written decision regarding the complaint within an
additional ten (10) business days.
(d) A health maintenance organization shall notify the enrollee or
subscriber in writing of the resolution of the grievance within five (5)
business days after completing the investigation. The grievance
resolution notice must contain the following:
(1) The decision reached by the health maintenance
organization.
(2) The reasons, policies, and procedures that are the basis of
the decision.
(3) Notice of the enrollee's or subscriber's right to appeal the
decision.
(4) The department, address, and telephone number through
which an enrollee may contact a qualified representative to
obtain more information about the decision or the right to
appeal. 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 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) Acknowledgment of the appeal, orally or in writing, within
three (3) business days after receipt of the appeal being 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 enrollees or subscribers of the disposition of
the appeal and that the enrollee or subscriber may have the right
to further remedies allowed by law.
(5) Standards for timeliness in responding to appeals and
providing notice to enrollees or subscribers of the disposition of
the appeal and the right to initiate an external appeals process
that accommodate the clinical urgency of the situation.
(b) The health maintenance organization shall appoint a panel of
qualified individuals to resolve an appeal. An individual may not be
appointed to the panel who has been involved in the matter giving
rise to the complaint or in the initial investigation of the complaint.
Except for grievances that have previously been appealed under
IC 27-8-17, in the case of an appeal from the proposal, refusal, or
delivery of a health care procedure, treatment, or service, the health
maintenance organization shall appoint one (1) or more individuals
to the panel to resolve the appeal. The panel must include one (1) or
more individuals who:
(1) have knowledge in the medical condition, procedure, or
treatment at issue;
(2) are in the same licensed profession as the provider who
proposed, refused, or delivered the health care procedure,
treatment, or service;
(3) are not involved in the matter giving rise to the appeal or the
previous grievance process; and
(4) do not have a direct business relationship with the enrollee
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 as
expeditiously as possible and with regard to the clinical urgency of
the appeal. However, an appeal must be resolved not later than
forty-five (45) days after the appeal is filed. A health maintenance
organization 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 a health maintenance organization violates subsection (c),
the health maintenance organization 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) A health maintenance organization shall allow enrollees and
subscribers the opportunity to appear in person at the panel or to
communicate with the panel through appropriate other means if the
enrollee or subscriber is unable to appear in person.
(f) A health maintenance organization shall notify the enrollee or
subscriber in writing of the resolution of the appeal of a grievance
within five (5) business days after completing the investigation. The
grievance resolution notice must contain the following:
(1) The decision reached by the health maintenance
organization.
(2) The reasons, policies, or procedures that are the basis of the
decision.
(3) Notice of the enrollee's or subscriber's right to further
remedies allowed by law, including the right to review by an
independent review organization under IC 27-13-10.1.
(4) The department, address, and telephone number through
which an enrollee may contact a qualified representative to
obtain more information about the decision or the right to an
appeal. 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 action
against a provider solely on the basis that the provider represents an
enrollee 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 shall
approve the grievance and appeals procedures of a health
maintenance organization if:
(1) the health maintenance organization certifies in writing to
the department of the health maintenance organization's
compliance with grievance and appeals procedures established
by the federal Centers for Medicare and Medicaid Services of
the United States Department of Health and Human Services;
and
(2) the department certifies that the grievance and appeals
procedures established by the federal Centers for Medicare and
Medicaid Services of the United States Department of Health
and Human Services are substantially similar to the grievance
and 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 maintenance
organization;
(3) release a health maintenance organization from the
prohibitions established under section 11 of this chapter; or
(4) require a health maintenance organization to use a grievance
and appeals procedure established by the federal Centers for
Medicare and Medicaid Services of the United States
Department 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 to
implement this chapter. As added by P.L.191-1997, SEC.13.
