Section 760IAC1-59-14. Grievance procedures report form

   The form required by section 4(a) of this rule is the following:

GRIEVANCE PROCEDURES REPORT
NAME: _______________________________
FOR REPORTING PERIOD January 1, ____ through December 31, ____
Block 1REPORTING COMPANY INFORMATION
NAIC Group Code:
Assumed business name(s):
Address:
General business telephone number:
Grievance reporting - toll free number:
Name, telephone number, and e-mail address of contact person for grievance procedures:
Languages in which grievances may be filed:
Total number of Indiana enrollees at beginning of reporting period:
Total number of Indiana enrollees at end of reporting period:
Service area (use applicable county codes; if the entire state, please indicate entire state rather than list all county codes):

Block 2GENERAL INFORMATION
Number of grievances filed		Number of appeals filed
Number of grievances resolved		Number of appeals resolved
Number of grievances resolved with Company position upheld		Number of appeals resolved with position upheld
Number of grievances resolved with Company position overturned		Number of appeals resolved with Company position overturned
Number of grievances pending		Number of appeals pending
Time to resolve grievances (average number of days)		Time to resolve appeals (average number of days)

INTERNAL GRIEVANCE AND APPEALS INFORMATION
Block 3NOTE: A grievance should not be recorded in more than one (1) category.
Basis	Number Filed	Company Position Upheld? Yes (#): No (#):	Number Pending	Average Number Of Days To Resolve	Appealed? Yes (#): No (#):	Company Position Upheld On Appeal? Yes (#): No (#):	Number Of Appeals Pending	Average Number Of Days To Resolve Appeals
DENIAL OR LIMITATION OF COVERED HEALTH CARE SERVICES
Inpatient services
Outpatient services
Emergency services
Mental or behavioral services
Home health care
Prescription drugs
Equipment or supplies
Laboratory services
Experimental treatments
Other services
HEALTH CARE PROVIDERS (for HMOs, LSHMOs, and Insurers with Network plans)
Quality of health care services
No referral or expired referral
Problem with particular provider not available
Problem with number of providers available
Problem with type of providers available
Problem with provider location
Problem getting appointment
OTHER BASIS FOR GRIEVANCE
Difficulty in enrolling/ other enrollment issues
Problem with claim payment or handling
Benefits limited or excluded
Timeliness of decision making
Other (attach additional sheets if necessary)

Block 4  DESCRIPTION OF GRIEVANCE PROCEDURES

Please describe your grievance procedures. Attach additional sheets as necessary:

Block 5  DESCRIPTION OF APPEALS PROCEDURES

Please describe your appeals procedures. Attach additional sheets as necessary:

(Department of Insurance; 760 IAC 1-59-14; filed Sep 30, 1998, 2:17 p.m.: 22 IR 451, eff Jan 1, 1999; filed Feb 17, 2003, 9:57 a.m.: 26 IR 2331; readopted filed Nov 24, 2009, 9:35 a.m.: 20091223-IR-760090791RFA; readopted filed Nov 20, 2015, 9:25 a.m.: 20151216-IR-760150341RFA)