Section 760IAC1-59-6. Establishment of grievance procedures; filing with and review by commissioner

   (a) An insurer, a health maintenance organization, and a limited service health maintenance organization shall establish and maintain grievance procedures.

  (b) A copy of the grievance procedures, including all forms used in filing and reviewing grievances, shall be included with any application for a certificate of authority submitted to the department.

  (c) Any material modifications to the grievance procedures subsequent to the submission of the application shall be filed with the commissioner not more than fifteen (15) days after the adoption of the modification.

  (d) The grievance procedures shall require the following:

(1) A health maintenance organization must provide written or oral acknowledgment of a grievance or appeal no more than three (3) business days after receipt. Insurers must provide written or oral acknowledgment of a grievance or appeal no more than five (5) business days after receipt. The acknowledgment must include the name, address, and telephone number of an individual to contact regarding the grievance and the date the grievance was filed.

(2) Investigation of any grievance or appeal in accordance with written procedures and the requirements of section 10 of this rule.

(3) Documentation of the substance of the grievance and all actions taken by the insurer or health maintenance organization regarding the grievance or appeal, including notification, acknowledgment, investigation, and resolution.

(4) Written notification to the enrollee of:

(A) resolution of the grievance or appeal;

(B) the right to appeal the resolution;

(C) information about how, when, and where to appeal the resolution; and

(D) the right to further remedies allowed by law, in the case of an appeal of a grievance resolution.

  (e) The grievance procedures shall include procedures to assist enrollees and representatives of enrollees in filing grievances and appeals, including provisions for assistance to persons with literacy, language, physical, health, or other impediments.

  (f) The grievance procedures shall include standards that meet the requirements of IC 27-8-28-17 or IC 27-13-10 and section 10 of this rule for timeliness in acknowledging, investigating, and resolving grievances and appeals and that accommodate the clinical urgency of the enrollee's situation. The standards for timeliness shall address:

(1) the likelihood of death, permanent injury, improvement, or deterioration of health status; and

(2) the ability to reach and maintain maximum function.

  (g) The grievance procedures must require expedited review of a grievance or appeal if the time periods set forth in section 10 of this rule would seriously jeopardize the life or health of an enrollee or the enrollee's ability to reach and maintain maximum function.

  (h) An HMO's grievance procedures must comply with the requirements of IC 27-13-39-3 with respect to any grievance regarding denial of coverage for a treatment, procedure, drug, or device on the grounds that it is experimental.

  (i) The grievance procedures shall require and describe the process for the appointment of at least one (1) individual who has sufficient experience, knowledge, and training to appropriately resolve a grievance or appeal.

  (j) The requirements of subsections (d) through (i) do not apply to a limited service health maintenance organization. (Department of Insurance; 760 IAC 1-59-6; filed Sep 30, 1998, 2:17 p.m.: 22 IR 447, eff Jan 1, 1999; errata, 22 IR 759; filed Feb 17, 2003, 9:57 a.m.: 26 IR 2328; readopted filed Nov 24, 2009, 9:35 a.m.: 20091223-IR-760090791RFA; readopted filed Nov 20, 2015, 9:25 a.m.: 20151216-IR-760150341RFA)