Section 760IAC1-49-9. Complaints and information

   (a) Within a reasonable time period, upon receipt of a written complaint alleging a violation of this section or IC 27-8-16 by a medical claims review agent, from an enrollee's health care provider, a person acting on behalf of the enrollee, or the enrollee, the commissioner or a designated department of insurance representative shall investigate the complaint and furnish a written response to the complainant and the medical claims review agent named. The response will not identify in any manner the patient or patients without written consent. This response must include the following:

(1) A statement of the original complaint.

(2) A copy of any written response by the medical claims review agent. The written response should not contain privileged medical records. If it is necessary to refer to medical records, they shall be forwarded separate from the response and clearly marked as privileged medical records.

(3) A statement of the findings of the commissioner or a designated department of insurance representative and an explanation of the basis of such findings.

(4) Corrective actions, if any, on the part of the medical claims review agent that the commissioner or a designated department of insurance representative finds appropriate.

(5) A time frame in which any corrective actions should be completed. The medical claims review agent will provide evidence of corrective action within the specified time frame to the commissioner or a designated department of insurance representative.

  (b) In addition to the authority of the commissioner to respond to complaints described in subsection (a), the department of insurance is authorized to address inquiries to medical claims review agents that the department of insurance may deem necessary for the public good or for a proper discharge of its duties. It shall be the duty of the agent to promptly answer such inquiries in writing.

  (c) The commissioner shall maintain and update a list of medical claims review agents issued certificates, including certificate numbers and the renewal date for those certificates. The commissioner shall provide the list at cost to all individuals or organizations requesting the list.

  (d) Requirements for on-site review by the department of insurance shall be as follows:

(1) The commissioner or a designated department of insurance representative is authorized to make a complete on-site review of the operations of each medical claims review agent at the principal place of business for such agent as often as is deemed necessary.

(2) Medical claims review agents will be notified of the scheduled on-site visit by letter which will specify, as a minimum, the identity of the commissioner's designated department of insurance representative and the expected arrival date and time.

(3) The medical claims review agent must make available during such on-site visits all records relating to its operation.

(4) The commissioner or the designated department of insurance representative may perform periodic telephone audits of medical claims review agents authorized to conduct business in this state to determine if the agents are reasonably accessible.

(Department of Insurance; 760 IAC 1-49-9; filed Dec 31, 1992, 9:00 a.m.: 16 IR 1398; errata filed Feb 10, 1993, 4:00 p.m.: 16 IR 1514; 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)