Section 760IAC1-49-3. Certification of medical claims review agents

   (a) An application for certification of a medical claims review agent must be filed with the department of insurance at 311 West Washington Street, Suite 300, Indianapolis, Indiana 46204. Initial applications must be filed on or before February 28, 1993.

  (b) The application, and fees as addressed in section 11 of this rule, must be submitted on a medical claims review agent application form that can be obtained from the department of insurance. The application form is adopted by reference and may be obtained from the Department of Insurance, 311 West Washington Street, Suite 300, Indianapolis, Indiana 46204.

  (c) The completed application form shall be accompanied by a summary of the following information:

(1) Procedures established for appeal of an adverse determination. These procedures must comply with section 6 of this rule.

(2) Policies and procedures that ensure that all applicable state and federal laws to protect the confidentiality of medical records are followed. These procedures must comply with section 8 of this rule.

  (d) The completed application form shall contain the following information:

(1) A certification that the medical claims review agent will comply with the provisions of IC 27-8-16.

(2) The categories of persons employed to perform medical claims review. Personnel changes within the categories do not constitute a material change in the application.

(3) A description of the hours of operation within the state of Indiana and how the medical claims review agent may be contacted during weekends and holidays. This description must be in compliance with section 7 of this rule.

(4) Representative samples of materials provided by the medical claims review agent or applicant to inform its clients, enrollees, or providers of the requirements of medical claims review.

(5) A certification that the medical claims review agent is in compliance with IC 27-8-16-11.

  (e) The medical claims review agent shall report any material changes in the information in the application or renewal form referred to in this section not later than the thirtieth day after the date on which the change takes effect.

  (f) The application process shall be as follows:

(1) The department of insurance shall have thirty (30) days after receipt of an application to determine whether the application is complete. In the event that an application is found to be incomplete, the department of insurance will give the applicant written notice of the required information necessary to complete the application. If the application is complete, the applicant will be advised that the application has been received and accepted for review.

(2) The department of insurance shall have sixty (60) days from the date the application is determined to be complete under subdivision (1) to process the application and approve or disapprove it. The department of insurance shall give the applicant written notice of any deficiencies noted as a result of the review conducted under this subdivision.

(3) The department of insurance shall afford the applicant an opportunity for a meeting to discuss any omissions or deficiencies noted.

(4) The applicant must correct the omissions or deficiencies in the application within thirty (30) days of the date of the latest notice of the department of insurance of such omissions or deficiencies. If the applicant fails to do so, the application file will be closed as an incomplete application. The application fee will not be refundable.

(5) The department of insurance shall maintain an application file that shall contain the application, notices of omissions or deficiencies, responses, and any written materials generated by any person who was considered by the department of insurance in evaluating the application.

  (g) A medical claims review agent must apply for a certificate renewal every year, not later than June 30. The initial renewal shall be completed by June 30, 1994. A renewal form must be used for this purpose. The renewal fee must be submitted with the renewal form. The renewal form can be obtained from the department of insurance at the address listed in subsection (a). The completed renewal form and the renewal fee must be submitted to the department of insurance at the address listed in subsection (a). A medical claims review agent may continue to operate under its certificate after a completed renewal application form and the renewal fee have been timely received by the department of insurance until the renewal is finally denied or issued by the department of insurance. If a completed renewal application and fee are not received prior to June 30, the certificate will automatically be canceled, and the medical claims review agent must complete and submit a new application form with the new application fee for another certificate of registration.

  (h) If an application or renewal is denied under this section, the applicant or registrant may appeal such denial under the terms of the provisions of IC 4-21.5. A hearing of such appeal shall be conducted within forty-five (45) days from the date the petition for hearing is filed with the commissioner. A decision by the commissioner shall be rendered within sixty (60) days from the date of the hearing.

  (i) Applications that are filed on or before February 28, 1993, will be processed on a first in, first out basis by the department of insurance. The time lines set out for processing applications in subsection (f) will not apply to these applications.

  (j) Entities that were operating in Indiana as medical claims review agents on or after July 1, 1992, must file the application described in subsections (a) through (d) by February 28, 1993. Those entities may continue to operate as medical claims review agents pending review of the application unless they are advised in writing that the application has been disapproved or closed as an incomplete application as described in subsection (f). No entity may continue to operate after fifteen (15) days from the date of the notice of the denial or closure of the file. (Department of Insurance; 760 IAC 1-49-3; filed Dec 31, 1992, 9:00 a.m.: 16 IR 1395; readopted filed Sep 14, 2001, 12:22 p.m.: 25 IR 531; readopted filed Nov 27, 2007, 4:01 p.m.: 20071226-IR-760070717RFA; readopted filed Nov 26, 2013, 3:43 p.m.: 20131225-IR-760130479RFA)