Sec. 17. (a) An insurer 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) Written or oral acknowledgment of the appeal not more than five (5) business days after the appeal is 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 the covered individual:
(A) of the disposition of an appeal; and
(B) that the covered individual may have the right to further remedies allowed by law.
(5) Standards for timeliness in:
(A) responding to an appeal; and
(B) providing notice to covered individuals of:
(i) the disposition of an appeal; and
(ii) the right to initiate an external grievance review under IC 27-8-29;
that accommodate the clinical urgency of the situation.
(b) In the case of an appeal of a grievance decision described in section 6(1) or 6(2) of this chapter, an insurer shall appoint a panel of one (1) or more qualified individuals to resolve an appeal. The panel must include one (1) or more individuals who:
(1) have knowledge of the medical condition, procedure, or treatment at issue;
(2) are licensed in the same profession and have a similar specialty as the provider who proposed or delivered the health care procedure, treatment, or service;
(3) are not involved in the matter giving rise to the appeal or in the initial investigation of the grievance; and
(4) do not have a direct business relationship with the covered individual 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:
(1) as expeditiously as possible, reflecting the clinical urgency of the situation; and
(2) not later than forty-five (45) days after the appeal is filed.
An insurer 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 an insurer violates subsection (c), the insurer 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) An insurer shall allow a covered individual the opportunity to:
(1) appear in person before; or
(2) if unable to appear in person, otherwise appropriately communicate with;
the panel appointed under subsection (b).
(f) An insurer shall notify a covered individual in writing of the resolution of an appeal of a grievance decision within five (5) business days after completing the investigation. The appeal resolution notice must include the following:
(1) A statement of the decision reached by the insurer.
(2) A statement of the reasons, policies, and procedures that are the basis of the decision.
(3) Notice of the covered individual's right to further remedies allowed by law, including the right to external grievance review by an independent review organization under IC 27-8-29.
(4) The department, address, and telephone number through which a covered individual may contact a qualified representative to obtain more information about the decision or the right to an external grievance review.
As added by P.L.66-2001, SEC.2 and P.L.203-2001, SEC.13. Amended by P.L.1-2002, SEC.116; P.L.178-2003, SEC.72.
