Indiana Code 27-8-16-8. Appeals procedure; written description; minimum standards; notice of appeal procedure on limitation or reduction of benefits
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Sec. 8. (a) An insurance company, a health maintenance organization, or another benefit program providing payment, reimbursement, or indemnification for health care costs that contracts with a claim review agent for medical claims review services shall maintain and make available upon request a written description of the appeals procedure by which an enrollee may seek a review of a determination by the claim review agent.
(1) On appeal, the determination must be made by a provider who holds a license in the same discipline as the provider who rendered the service.
(b) The appeals procedure referred to in subsection (a) must meet the following requirements:
Terms Used In Indiana Code 27-8-16-8
- Appeal: A request made after a trial, asking another court (usually the court of appeals) to decide whether the trial was conducted properly. To make such a request is "to appeal" or "to take an appeal." One who appeals is called the appellant.
- claim review agent: means any entity performing medical claims review on behalf of an insurance company, a health maintenance organization, or another benefit program providing payment, reimbursement, or indemnification for health care costs to an enrollee. See Indiana Code 27-8-16-1
- enrollee: means an individual who has contracted for or who participates in coverage under an insurance policy, a health maintenance organization contract, or another benefit program providing payment, reimbursement, or indemnification for the costs of health care for:
Indiana Code 27-8-16-3
- Indemnification: In general, a collateral contract or assurance under which one person agrees to secure another person against either anticipated financial losses or potential adverse legal consequences. Source: FDIC
- medical claims review: means the determination of the reimbursement to be provided under the terms of an insurance policy, a health maintenance organization contract, or another benefit program providing payment, reimbursement, or indemnification for health care costs based on the appropriateness of health care services or the amount charged for a health care service delivered to an enrollee. See Indiana Code 27-8-16-4
(2) The adjudication of an appeal of a determination must be completed within thirty (30) days after:
(A) the appeal is filed; and
(B) all information necessary to complete the appeal is received.
(c) If a medical review determination results in a limitation or reduction of benefits, a notice of the appeals procedure shall be provided by the claim review agent to the provider who rendered the health care services.
As added by P.L.128-1992, SEC.2.