Indiana Code 27-8-29-12. Insurer to establish external grievance procedures
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Sec. 12. An insurer shall establish and maintain an external grievance procedure for the resolution of external grievances regarding the following:
(A) An adverse determination of appropriateness.
(1) The following determinations made by the insurer or an agent of the insurer regarding a service proposed by the treating health care provider:
Terms Used In Indiana Code 27-8-29-12
- accident and sickness insurance policy: has the meaning set forth in IC 27-8-28-1. See Indiana Code 27-8-29-1
- external grievance: means the independent review under this chapter of a:
Indiana Code 27-8-29-6
- health care provider: means a person:
Indiana Code 27-8-29-9
- insurer: has the meaning set forth in IC 27-8-28-9. See Indiana Code 27-8-29-11
(B) An adverse determination of medical necessity.
(C) A determination that a proposed service is experimental or investigational.
(D) A denial of coverage based on a waiver described in IC 27-8-5-2.5(e) (expired July 1, 2007, and removed) or IC 27-8-5-19.2 (expired July 1, 2007, and repealed).
(2) The insurer’s decision to rescind an accident and sickness insurance policy.
As added by P.L.66-2001, SEC.3 and P.L.203-2001, SEC.14. Amended by P.L.211-2003, SEC.7; P.L.3-2008, SEC.216; P.L.160-2011, SEC.23.