Sec. 1. A health maintenance organization shall establish and maintain an external grievance procedure for the resolution of grievances regarding the following:
(1) The following determinations made by the health maintenance organization or an agent of the health maintenance organization regarding a service proposed by the treating physician:
(A) An adverse utilization review determination (as defined in IC 27-8-17-8).
(B) An adverse determination of medical necessity.
(C) A determination that a proposed service is experimental or investigational.
(2) The health maintenance organization's decision to rescind an individual contract or a group contract.
As added by P.L.133-1999, SEC.7. Amended by P.L.160-2011, SEC.28.
Structure Indiana Code
Article 13. Health Maintenance Organizations
Chapter 10.1. External Review of Grievances
27-13-10.1-0.1. Application of Chapter
27-13-10.1-1. External Grievance Procedure Established
27-13-10.1-2. Requirements of Procedure
27-13-10.1-3. Cooperation With Review Organization; Requirements of Enrollee
27-13-10.1-4. Requirements of Independent Review Organization
27-13-10.1-4.5. Information From Independent Review Organization
27-13-10.1-5. Determination Binding on Health Maintenance Organization
27-13-10.1-6. Reconsideration of Resolution
27-13-10.1-7. Terms of Coverage Unchanged
27-13-10.1-8. Certification of Independent Review Organizations
27-13-10.1-10. Immunity From Civil Liability