2023 Indiana Code
Title 27. Insurance
Article 13. Health Maintenance Organizations
Chapter 10.1. External Review of Grievances
27-13-10.1-4. Requirements of Independent Review Organization
Sec. 4. (a) An independent review organization shall:
(1) for an expedited appeal filed under section 2(a)(2)(A) of this chapter, within seventy-two (72) hours after the appeal is filed; or
(2) for a standard appeal filed under section 2(a)(2)(B) of this chapter, within fifteen (15) business days after the appeal is filed;
make a determination to uphold or reverse the health maintenance organization's grievance resolution under IC 27-13-10-8 based on information gathered from the enrollee or the enrollee's designee, the health maintenance organization, and the treating physician, and any additional information that the independent review organization considers necessary and appropriate.
(b) When making the determination under this section, the independent review organization shall apply:
(1) standards of decision making that are based on objective clinical evidence; and
(2) the terms of the enrollee's benefit contract.
(c) The independent review organization shall notify the health maintenance organization and the enrollee of the determination made under this section:
(1) for an expedited appeal filed under section 2(a)(2)(A) of this chapter, within seventy-two (72) hours after the appeal is filed; or
(2) for a standard appeal filed under section 2(a)(2)(B) of this chapter, within seventy-two (72) hours after making the determination.
As added by P.L.133-1999, SEC.7. Amended by P.L.72-2016, SEC.26.
