Section 760 IAC 1-59-10 - Standards for timely review and resolution of grievancesAuthority: IC 27-8-28-20; IC 27-13-10-13; IC 27-13-35-1
Affected: IC 27-8-28; IC 27-13-10-7; IC 27-13-10-8
Sec. 10.
(a) Minimum standards for timely review and resolution of grievances filed with an insurer or a health maintenance organization are as follows: (1) A health maintenance organization shall provide oral or written acknowledgment of a filed grievance to an enrollee not more than three (3) business days after the grievance is filed. An insurer shall provide oral or written acknowledgment of a filed grievance to an enrollee or an enrollee's representative not more than five (5) business days after the grievance is filed. (2) A health maintenance organization shall resolve a grievance not more than twenty (20) business days after the grievance is filed. An insurer shall resolve a grievance not more than twenty (20) business days after the insurer receives all information reasonably necessary to complete the review.(3) Written notification to an enrollee of the resolution of a grievance not more than five (5) business days after the resolution. (4) The time period set forth in subdivision (2) may be extended if an insurer or a health maintenance organization is unable to resolve a grievance within the specified time period due to circumstances beyond the insurer's or the health maintenance organization's control. An enrollee must be notified in writing of the reason for the delay not more than nineteen (19) business days after the grievance is filed. The insurer or the health maintenance organization shall issue a written notification of the resolution of the grievance not more than ten (10) business days after the notification to the enrollee of the delay.(b) As used in this rule, "circumstances beyond the insurer's or the health maintenance organization's control" means the following:(1) The failure of a provider that is not a participating provider to provide within fifteen (15) days of the filing of the grievance information that is requested by the insurer or the health maintenance organization and is necessary to adequately review and investigate the grievance.(2) The failure of an enrollee to provide additional information requested by the insurer or the health maintenance organization that is necessary to resolve the grievance within fifteen (15) days of the filing of the grievance.(c) Minimum standards for timely review and resolution of grievance resolution appeals filed with an insurer or a health maintenance organization are as follows: (1) Oral or written acknowledgment by a health maintenance organization to an enrollee of a filed appeal not more than three (3) business days after the appeal is filed. Oral or written acknowledgment by an insurer to a covered individual of a filed appeal not more than five (5) business days after the appeal is filed.(2) Resolution of the appeal not more than forty-five (45) business days after the appeal is filed.(3) Written notification to an enrollee of the resolution of an appeal not more than five (5) business days after the resolution. Department of Insurance; 760 IAC 1-59-10; filed Sep 30, 1998, 2:17 p.m.: 22 IR 449, eff Jan 1, 1999; filed Feb 17, 2003, 9:57 a.m.: 26 IR 2330; readopted filed Nov 24, 2009, 9:35 a.m.: 20091223-IR-760090791RFAReadopted filed 11/20/2015, 9:25 a.m.: 20151216-IR-760150341RFAReadopted filed 11/15/2021, 8:32 a.m.: 20211215-IR-760210419RFA