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 and
maintain an external grievance procedure for the resolution of
grievances regarding:
(1) an adverse utilization review determination (as defined in
IC 27-8-17-8);
(2) an adverse determination of medical necessity; or
(3) a determination that a proposed service is experimental or
investigational;
made by a health maintenance organization or an agent of a health
maintenance organization regarding a service proposed by the
treating 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 under
section 1 of this chapter must:
(1) allow an enrollee or the enrollee's representative to file a
written request with the health maintenance organization for an
appeal of the health maintenance organization's grievance
resolution under IC 27-13-10-8 not later than forty-five (45)
days after the enrollee is notified of the resolution under
IC 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 would
seriously 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 health
maintenance organization's grievance resolution under this chapter.
(b) Subject to the requirements of subsection (d), when a request
is filed under subsection (a), the health maintenance organization
shall:
(1) select a different independent review organization for each
appeal filed under this chapter from the list of independent
review organizations that are certified by the department under
section 8 of this chapter; and
(2) rotate the choice of an independent review organization
among all certified independent review organizations before
repeating a selection.
(c) The independent review organizations shall assign a medical
review professional who is board certified in the applicable specialty
for resolution of an appeal.
(d) The independent review organization and the medical review
professional conducting the external review under this chapter may
not have a material professional, familial, financial, or other
affiliation with any of the following:
(1) The health maintenance organization.
(2) Any officer, director, or management employee of the health
maintenance organization.
(3) The physician or the physician's medical 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 by the
treating physician.
However, the medical review professional may have an affiliation
under which the medical review professional provides health care
services to enrollees of the health maintenance organization and may
have an affiliation that is limited to staff privileges at the health
facility if the affiliation is disclosed to the enrollee and the health
maintenance organization before commencing the review and neither
the enrollee nor the health maintenance organization objects.
(e) The enrollee may be required to pay not more than twenty-five
dollars ($25) of the costs associated with the services of an
independent review organization under this chapter. All additional
costs 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 chapter
shall:
(1) not be subject to retaliation for exercising the enrollee's
right to an appeal under this chapter;
(2) be permitted to utilize the assistance of other individuals,
including physicians, attorneys, friends, and family members
throughout the review process;
(3) be permitted to submit additional information relating to the
proposed 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 an
independent review organization selected under section 2 of this
chapter by promptly providing any information requested by the
independent 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 this
chapter, within seventy-two (72) hours after the appeal is filed;
or
(2) for a standard appeal filed under section 2(a)(2)(B) of this
chapter, within fifteen (15) business days after the appeal is
filed;
make a determination to uphold or reverse the health maintenance
organization's grievance resolution under IC 27-13-10-8 based on
information gathered from the enrollee or the enrollee's designee, the
health maintenance organization, and the treating physician, 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 enrollee's benefit contract.
(c) The independent review organization shall notify the health
maintenance organization and the enrollee of the determination made
under this section:
(1) for an expedited appeal filed under section 2(a)(2)(A) of this
chapter, within twenty-four (24) hours after making the
determination; or
(2) for a standard appeal filed under section 2(a)(2)(B) of this
chapter, within seventy-two (72) hours after making the
determination. 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 under
section 4(c) of this chapter that the independent review organization
has made a determination, the independent review organization shall
provide to the enrollee all information reasonably necessary to
enable the enrollee to understand the:
(1) effect of the determination on the enrollee; and
(2) manner in which the health maintenance organization may
be 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 is
binding 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 performed
under this chapter, the enrollee submits information to the health
maintenance organization that is relevant to the health maintenance
organization's resolution under IC 27-13-10-8 and was not considered
by the health maintenance organization under IC 27-13-10:
(1) the health maintenance organization shall reconsider the
health maintenance organization's resolution under
IC 27-13-10-8; and
(2) the independent review organization shall cease the external
review process until the reconsideration under subsection (b) is
completed.
(b) A health maintenance organization to which information is
submitted under subsection (a) shall reconsider the resolution under
IC 27-13-10-8 based on the information and notify the enrollee of the
health maintenance organization's decision:
(1) within seventy-two (72) hours after the information is
submitted for a reconsideration related to an illness, a disease,
a condition, an injury, or a disability that would seriously
jeopardize 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 submitted
for a reconsideration not described in subdivision (1).
(c) If the decision reached under subsection (b) is adverse to the
enrollee, the enrollee may request that the independent review
organization 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 terms
of coverage included in a contract under which an enrollee receives
health 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 process
for annual certification of independent review organizations.
(b) The department shall certify a number of independent review
organizations determined by the department to be sufficient to fulfill
the purposes of this chapter.
(c) An independent review organization shall meet the following
minimum requirements for certification by the department:
(1) Medical review professionals assigned by the independent
review organization to perform external grievance reviews
under this chapter:
(A) must be board certified in the specialty in which an
enrollee's proposed service would be provided;
(B) must be knowledgeable about a proposed service
through 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 sanctions
including:
(i) loss of staff privileges; or
(ii) restriction on participation;
taken or pending by any hospital, government, or regulatory
body.
(2) The independent review organization must have a quality
assurance mechanism to ensure the:
(A) timeliness and quality of reviews;
(B) qualifications and independence of medical review
professionals;
(C) confidentiality of medical records and other review
materials; and
(D) satisfaction of enrollees with the procedures utilized by
the independent review organization, including the use of
enrollee satisfaction surveys.
(3) The independent review organization must file with the
department the following information before March 1 of each
year:
(A) The number and percentage of determinations made in
favor of enrollees.
(B) The number and percentage of determinations made in
favor 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 be
specified for each health maintenance organization for which
the independent review organization performed reviews during
the reporting year.
(4) Any additional requirements established by the department.
(d) The department may not certify an independent review
organization that is one (1) of the following:
(1) A professional or trade association of health care providers
or a subsidiary or an affiliate of a professional or trade
association of health care providers.
(2) A health insurer, health maintenance organization, or health
plan association or a subsidiary or an affiliate of a health
insurer, health maintenance organization, or health plan
association.
(e) The department may suspend or revoke an independent review
organization's certification if the department finds that the
independent review organization is not in substantial compliance
with the certification requirements under this section.
(f) The department shall make available to health maintenance
organizations a list of all certified independent review organizations.
(g) The department shall make the information provided to the
department under subsection (c)(3) available to the public in a format
that 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 the
independent review organization or the medical review professional
in 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 confidentiality
requirements 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 from
civil liability for actions taken in good faith in connection with an
external review under this chapter.
(b) The work product or determination, or both, of an independent
review organization under this chapter are admissible in a judicial or
administrative proceeding. However, the work product or
determination, or both, do not, without other supporting evidence,
satisfy any party's burden of proof or persuasion concerning any
material 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 under
Medicare (42 U.S.C. 1395 et seq.) the enrollee may not request an
external 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 to
implement this chapter. As added by P.L.133-1999, SEC.7.
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 and
maintain an external grievance procedure for the resolution of
grievances regarding:
(1) an adverse utilization review determination (as defined in
IC 27-8-17-8);
(2) an adverse determination of medical necessity; or
(3) a determination that a proposed service is experimental or
investigational;
made by a health maintenance organization or an agent of a health
maintenance organization regarding a service proposed by the
treating 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 under
section 1 of this chapter must:
(1) allow an enrollee or the enrollee's representative to file a
written request with the health maintenance organization for an
appeal of the health maintenance organization's grievance
resolution under IC 27-13-10-8 not later than forty-five (45)
days after the enrollee is notified of the resolution under
IC 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 would
seriously 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 health
maintenance organization's grievance resolution under this chapter.
(b) Subject to the requirements of subsection (d), when a request
is filed under subsection (a), the health maintenance organization
shall:
(1) select a different independent review organization for each
appeal filed under this chapter from the list of independent
review organizations that are certified by the department under
section 8 of this chapter; and
(2) rotate the choice of an independent review organization
among all certified independent review organizations before
repeating a selection.
(c) The independent review organizations shall assign a medical
review professional who is board certified in the applicable specialty
for resolution of an appeal.
(d) The independent review organization and the medical review
professional conducting the external review under this chapter may
not have a material professional, familial, financial, or other
affiliation with any of the following:
(1) The health maintenance organization.
(2) Any officer, director, or management employee of the health
maintenance organization.
(3) The physician or the physician's medical 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 by the
treating physician.
However, the medical review professional may have an affiliation
under which the medical review professional provides health care
services to enrollees of the health maintenance organization and may
have an affiliation that is limited to staff privileges at the health
facility if the affiliation is disclosed to the enrollee and the health
maintenance organization before commencing the review and neither
the enrollee nor the health maintenance organization objects.
(e) The enrollee may be required to pay not more than twenty-five
dollars ($25) of the costs associated with the services of an
independent review organization under this chapter. All additional
costs 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 chapter
shall:
(1) not be subject to retaliation for exercising the enrollee's
right to an appeal under this chapter;
(2) be permitted to utilize the assistance of other individuals,
including physicians, attorneys, friends, and family members
throughout the review process;
(3) be permitted to submit additional information relating to the
proposed 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 an
independent review organization selected under section 2 of this
chapter by promptly providing any information requested by the
independent 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 this
chapter, within seventy-two (72) hours after the appeal is filed;
or
(2) for a standard appeal filed under section 2(a)(2)(B) of this
chapter, within fifteen (15) business days after the appeal is
filed;
make a determination to uphold or reverse the health maintenance
organization's grievance resolution under IC 27-13-10-8 based on
information gathered from the enrollee or the enrollee's designee, the
health maintenance organization, and the treating physician, 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 enrollee's benefit contract.
(c) The independent review organization shall notify the health
maintenance organization and the enrollee of the determination made
under this section:
(1) for an expedited appeal filed under section 2(a)(2)(A) of this
chapter, within twenty-four (24) hours after making the
determination; or
(2) for a standard appeal filed under section 2(a)(2)(B) of this
chapter, within seventy-two (72) hours after making the
determination. 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 under
section 4(c) of this chapter that the independent review organization
has made a determination, the independent review organization shall
provide to the enrollee all information reasonably necessary to
enable the enrollee to understand the:
(1) effect of the determination on the enrollee; and
(2) manner in which the health maintenance organization may
be 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 is
binding 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 performed
under this chapter, the enrollee submits information to the health
maintenance organization that is relevant to the health maintenance
organization's resolution under IC 27-13-10-8 and was not considered
by the health maintenance organization under IC 27-13-10:
(1) the health maintenance organization shall reconsider the
health maintenance organization's resolution under
IC 27-13-10-8; and
(2) the independent review organization shall cease the external
review process until the reconsideration under subsection (b) is
completed.
(b) A health maintenance organization to which information is
submitted under subsection (a) shall reconsider the resolution under
IC 27-13-10-8 based on the information and notify the enrollee of the
health maintenance organization's decision:
(1) within seventy-two (72) hours after the information is
submitted for a reconsideration related to an illness, a disease,
a condition, an injury, or a disability that would seriously
jeopardize 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 submitted
for a reconsideration not described in subdivision (1).
(c) If the decision reached under subsection (b) is adverse to the
enrollee, the enrollee may request that the independent review
organization 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 terms
of coverage included in a contract under which an enrollee receives
health 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 process
for annual certification of independent review organizations.
(b) The department shall certify a number of independent review
organizations determined by the department to be sufficient to fulfill
the purposes of this chapter.
(c) An independent review organization shall meet the following
minimum requirements for certification by the department:
(1) Medical review professionals assigned by the independent
review organization to perform external grievance reviews
under this chapter:
(A) must be board certified in the specialty in which an
enrollee's proposed service would be provided;
(B) must be knowledgeable about a proposed service
through 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 sanctions
including:
(i) loss of staff privileges; or
(ii) restriction on participation;
taken or pending by any hospital, government, or regulatory
body.
(2) The independent review organization must have a quality
assurance mechanism to ensure the:
(A) timeliness and quality of reviews;
(B) qualifications and independence of medical review
professionals;
(C) confidentiality of medical records and other review
materials; and
(D) satisfaction of enrollees with the procedures utilized by
the independent review organization, including the use of
enrollee satisfaction surveys.
(3) The independent review organization must file with the
department the following information before March 1 of each
year:
(A) The number and percentage of determinations made in
favor of enrollees.
(B) The number and percentage of determinations made in
favor 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 be
specified for each health maintenance organization for which
the independent review organization performed reviews during
the reporting year.
(4) Any additional requirements established by the department.
(d) The department may not certify an independent review
organization that is one (1) of the following:
(1) A professional or trade association of health care providers
or a subsidiary or an affiliate of a professional or trade
association of health care providers.
(2) A health insurer, health maintenance organization, or health
plan association or a subsidiary or an affiliate of a health
insurer, health maintenance organization, or health plan
association.
(e) The department may suspend or revoke an independent review
organization's certification if the department finds that the
independent review organization is not in substantial compliance
with the certification requirements under this section.
(f) The department shall make available to health maintenance
organizations a list of all certified independent review organizations.
(g) The department shall make the information provided to the
department under subsection (c)(3) available to the public in a format
that 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 the
independent review organization or the medical review professional
in 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 confidentiality
requirements 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 from
civil liability for actions taken in good faith in connection with an
external review under this chapter.
(b) The work product or determination, or both, of an independent
review organization under this chapter are admissible in a judicial or
administrative proceeding. However, the work product or
determination, or both, do not, without other supporting evidence,
satisfy any party's burden of proof or persuasion concerning any
material 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 under
Medicare (42 U.S.C. 1395 et seq.) the enrollee may not request an
external 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 to
implement this chapter. As added by P.L.133-1999, SEC.7.
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 and
maintain an external grievance procedure for the resolution of
grievances regarding:
(1) an adverse utilization review determination (as defined in
IC 27-8-17-8);
(2) an adverse determination of medical necessity; or
(3) a determination that a proposed service is experimental or
investigational;
made by a health maintenance organization or an agent of a health
maintenance organization regarding a service proposed by the
treating 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 under
section 1 of this chapter must:
(1) allow an enrollee or the enrollee's representative to file a
written request with the health maintenance organization for an
appeal of the health maintenance organization's grievance
resolution under IC 27-13-10-8 not later than forty-five (45)
days after the enrollee is notified of the resolution under
IC 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 would
seriously 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 health
maintenance organization's grievance resolution under this chapter.
(b) Subject to the requirements of subsection (d), when a request
is filed under subsection (a), the health maintenance organization
shall:
(1) select a different independent review organization for each
appeal filed under this chapter from the list of independent
review organizations that are certified by the department under
section 8 of this chapter; and
(2) rotate the choice of an independent review organization
among all certified independent review organizations before
repeating a selection.
(c) The independent review organizations shall assign a medical
review professional who is board certified in the applicable specialty
for resolution of an appeal.
(d) The independent review organization and the medical review
professional conducting the external review under this chapter may
not have a material professional, familial, financial, or other
affiliation with any of the following:
(1) The health maintenance organization.
(2) Any officer, director, or management employee of the health
maintenance organization.
(3) The physician or the physician's medical 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 by the
treating physician.
However, the medical review professional may have an affiliation
under which the medical review professional provides health care
services to enrollees of the health maintenance organization and may
have an affiliation that is limited to staff privileges at the health
facility if the affiliation is disclosed to the enrollee and the health
maintenance organization before commencing the review and neither
the enrollee nor the health maintenance organization objects.
(e) The enrollee may be required to pay not more than twenty-five
dollars ($25) of the costs associated with the services of an
independent review organization under this chapter. All additional
costs 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 chapter
shall:
(1) not be subject to retaliation for exercising the enrollee's
right to an appeal under this chapter;
(2) be permitted to utilize the assistance of other individuals,
including physicians, attorneys, friends, and family members
throughout the review process;
(3) be permitted to submit additional information relating to the
proposed 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 an
independent review organization selected under section 2 of this
chapter by promptly providing any information requested by the
independent 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 this
chapter, within seventy-two (72) hours after the appeal is filed;
or
(2) for a standard appeal filed under section 2(a)(2)(B) of this
chapter, within fifteen (15) business days after the appeal is
filed;
make a determination to uphold or reverse the health maintenance
organization's grievance resolution under IC 27-13-10-8 based on
information gathered from the enrollee or the enrollee's designee, the
health maintenance organization, and the treating physician, 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 enrollee's benefit contract.
(c) The independent review organization shall notify the health
maintenance organization and the enrollee of the determination made
under this section:
(1) for an expedited appeal filed under section 2(a)(2)(A) of this
chapter, within twenty-four (24) hours after making the
determination; or
(2) for a standard appeal filed under section 2(a)(2)(B) of this
chapter, within seventy-two (72) hours after making the
determination. 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 under
section 4(c) of this chapter that the independent review organization
has made a determination, the independent review organization shall
provide to the enrollee all information reasonably necessary to
enable the enrollee to understand the:
(1) effect of the determination on the enrollee; and
(2) manner in which the health maintenance organization may
be 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 is
binding 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 performed
under this chapter, the enrollee submits information to the health
maintenance organization that is relevant to the health maintenance
organization's resolution under IC 27-13-10-8 and was not considered
by the health maintenance organization under IC 27-13-10:
(1) the health maintenance organization shall reconsider the
health maintenance organization's resolution under
IC 27-13-10-8; and
(2) the independent review organization shall cease the external
review process until the reconsideration under subsection (b) is
completed.
(b) A health maintenance organization to which information is
submitted under subsection (a) shall reconsider the resolution under
IC 27-13-10-8 based on the information and notify the enrollee of the
health maintenance organization's decision:
(1) within seventy-two (72) hours after the information is
submitted for a reconsideration related to an illness, a disease,
a condition, an injury, or a disability that would seriously
jeopardize 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 submitted
for a reconsideration not described in subdivision (1).
(c) If the decision reached under subsection (b) is adverse to the
enrollee, the enrollee may request that the independent review
organization 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 terms
of coverage included in a contract under which an enrollee receives
health 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 process
for annual certification of independent review organizations.
(b) The department shall certify a number of independent review
organizations determined by the department to be sufficient to fulfill
the purposes of this chapter.
(c) An independent review organization shall meet the following
minimum requirements for certification by the department:
(1) Medical review professionals assigned by the independent
review organization to perform external grievance reviews
under this chapter:
(A) must be board certified in the specialty in which an
enrollee's proposed service would be provided;
(B) must be knowledgeable about a proposed service
through 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 sanctions
including:
(i) loss of staff privileges; or
(ii) restriction on participation;
taken or pending by any hospital, government, or regulatory
body.
(2) The independent review organization must have a quality
assurance mechanism to ensure the:
(A) timeliness and quality of reviews;
(B) qualifications and independence of medical review
professionals;
(C) confidentiality of medical records and other review
materials; and
(D) satisfaction of enrollees with the procedures utilized by
the independent review organization, including the use of
enrollee satisfaction surveys.
(3) The independent review organization must file with the
department the following information before March 1 of each
year:
(A) The number and percentage of determinations made in
favor of enrollees.
(B) The number and percentage of determinations made in
favor 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 be
specified for each health maintenance organization for which
the independent review organization performed reviews during
the reporting year.
(4) Any additional requirements established by the department.
(d) The department may not certify an independent review
organization that is one (1) of the following:
(1) A professional or trade association of health care providers
or a subsidiary or an affiliate of a professional or trade
association of health care providers.
(2) A health insurer, health maintenance organization, or health
plan association or a subsidiary or an affiliate of a health
insurer, health maintenance organization, or health plan
association.
(e) The department may suspend or revoke an independent review
organization's certification if the department finds that the
independent review organization is not in substantial compliance
with the certification requirements under this section.
(f) The department shall make available to health maintenance
organizations a list of all certified independent review organizations.
(g) The department shall make the information provided to the
department under subsection (c)(3) available to the public in a format
that 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 the
independent review organization or the medical review professional
in 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 confidentiality
requirements 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 from
civil liability for actions taken in good faith in connection with an
external review under this chapter.
(b) The work product or determination, or both, of an independent
review organization under this chapter are admissible in a judicial or
administrative proceeding. However, the work product or
determination, or both, do not, without other supporting evidence,
satisfy any party's burden of proof or persuasion concerning any
material 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 under
Medicare (42 U.S.C. 1395 et seq.) the enrollee may not request an
external 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 to
implement this chapter. As added by P.L.133-1999, SEC.7.
