reglab/housing_qa huggingface dataset:
IN Code § 27-13-10-7 (2021)
2021 Indiana Code|Title 27. Insurance|Article 13. Health Maintenance Organizations|Chapter 10. Grievance Procedures|27-13-10-7. Resolution of Grievances

Sec. 7. (a) A health maintenance organization shall establish written policies and procedures for the timely resolution of grievances filed under this chapter. The policies and procedures must include the following:(1) An acknowledgment of the grievance, orally or in writing, to the enrollee or subscriber within three (3) business days.(2) Documentation of the substance of the grievance and any actions taken.(3) An investigation of the substance of the grievance, including any aspects involving clinical care.(4) Notification to the enrollee or subscriber of the disposition of the grievance and the right to appeal.(5) Standards for timeliness in responding to complaints and providing notice to enrollees and subscribers of the disposition of the complaint and the right to appeal that accommodate the clinical urgency of the situation.(b) The health maintenance organization shall appoint at least one (1) individual to resolve the complaint.(c) A grievance must be resolved as expeditiously as possible, but not more than twenty (20) business days after the grievance is filed. If a health maintenance organization is unable to make a decision regarding the grievance within the twenty (20) day period due to circumstances beyond the health maintenance organization's control, the health maintenance organization shall:(1) notify the enrollee or subscriber in writing of the reason for the delay before the twentieth business day; and(2) issue a written decision regarding the complaint within an additional ten (10) business days.(d) A health maintenance organization shall notify the enrollee or subscriber in writing of the resolution of the grievance within five (5) business days after completing the investigation. The grievance resolution notice must contain the following:(1) The decision reached by the health maintenance organization.(2) The reasons, policies, and procedures that are the basis of the decision.(3) Notice of the enrollee's or subscriber's right to appeal the decision.(4) The department, address, and telephone number through which an enrollee may contact a qualified representative to obtain more information about the decision or the right to appeal.As added by P.L.191-1997, SEC.9.
IN Code § 27-13-10-11 (2021)
2021 Indiana Code|Title 27. Insurance|Article 13. Health Maintenance Organizations|Chapter 10. Grievance Procedures|27-13-10-11. Action Against Provider Representing Enrollee or Subscriber

Sec. 11. A health maintenance organization may not take action against a provider solely on the basis that the provider represents an enrollee or subscriber in a grievance filed under this chapter.As added by P.L.191-1997, SEC.11.
IN Code § 27-13-10-12 (2021)
2021 Indiana Code|Title 27. Insurance|Article 13. Health Maintenance Organizations|Chapter 10. Grievance Procedures|27-13-10-12. Approval of Grievance and Appeals Procedures

Sec. 12. (a) Notwithstanding IC 27-13, the department shall approve the grievance and appeals procedures of a health maintenance organization if:(1) the health maintenance organization certifies in writing to the department of the health maintenance organization's compliance with grievance and appeals procedures established by the federal Centers for Medicare and Medicaid Services of the United States Department of Health and Human Services; and(2) the department certifies that the grievance and appeals procedures established by the federal Centers for Medicare and Medicaid Services of the United States Department of Health and Human Services are substantially similar to the grievance and appeals process in IC 27-13.(b) Subsection (a) does not:(1) limit the authority of the department;(2) limit the responsibility of a health maintenance organization;(3) release a health maintenance organization from the prohibitions established under section 11 of this chapter; or(4) require a health maintenance organization to use a grievance and appeals procedure established by the federal Centers for Medicare and Medicaid Services of the United States Department of Health and Human Services.As added by P.L.191-1997, SEC.12. Amended by P.L.66-2002, SEC.17.
IN Code § 27-13-10-13 (2021)
2021 Indiana Code|Title 27. Insurance|Article 13. Health Maintenance Organizations|Chapter 10. Grievance Procedures|27-13-10-13. Adoption of Rules

Sec. 13. The department may adopt rules under IC 4-22-2 to implement this chapter.As added by P.L.191-1997, SEC.13.
IN Code § 27-13-10.1-0.1 (2021)
2021 Indiana Code|Title 27. Insurance|Article 13. Health Maintenance Organizations|Chapter 10.1. External Review of Grievances|27-13-10.1-0.1. Application of Chapter

Sec. 0.1. The addition of this chapter by P.L.133-1999 applies to grievances filed under IC 27-13-10-5 after January 1, 2000.As added by P.L.220-2011, SEC.459.
IN Code § 27-13-10.1-1 (2021)
2021 Indiana Code|Title 27. Insurance|Article 13. Health Maintenance Organizations|Chapter 10.1. External Review of Grievances|27-13-10.1-1. External Grievance Procedure Established

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.
IN Code § 27-13-10.1-2 (2021)
2021 Indiana Code|Title 27. Insurance|Article 13. Health Maintenance Organizations|Chapter 10.1. External Review of Grievances|27-13-10.1-2. Requirements of Procedure

Sec. 2. (a) An external grievance procedure established under section 1 of this chapter must:(1) allow an enrollee or the enrollee's representative to file a written request with the health maintenance organization for an appeal of the health maintenance organization's grievance resolution under IC 27-13-10-8 not later than one hundred twenty (120) days after the enrollee is notified of the resolution under IC 27-13-10-8; and(2) provide for:(A) an expedited appeal for a grievance related to an illness, a disease, a condition, an injury, or a disability that would seriously jeopardize the enrollee's:(i) life or health; or(ii) ability to reach and maintain maximum function; or(B) a standard appeal for a grievance not described in clause (A).An enrollee may file not more than one (1) appeal of a health maintenance organization's grievance resolution under this chapter.(b) Subject to the requirements of subsection (d), when a request is filed under subsection (a), the health maintenance organization shall:(1) select a different independent review organization for each appeal filed under this chapter from the list of independent review organizations that are certified by the department under section 8 of this chapter; and(2) rotate the choice of an independent review organization among all certified independent review organizations before repeating a selection.(c) The independent review organizations shall assign a medical review professional who is board certified in the applicable specialty for resolution of an appeal.(d) The independent review organization and the medical review professional conducting the external review under this chapter may not have a material professional, familial, financial, or other affiliation with any of the following:(1) The health maintenance organization.(2) Any officer, director, or management employee of the health maintenance organization.(3) The physician or the physician's medical group that is proposing the service.(4) The facility at which the service would be provided.(5) The development or manufacture of the principal drug, device, procedure, or other therapy that is proposed by the treating physician.However, the medical review professional may have an affiliation under which the medical review professional provides health care services to enrollees of the health maintenance organization and may have an affiliation that is limited to staff privileges at the health facility if the affiliation is disclosed to the enrollee and the health maintenance organization before commencing the review and neither the enrollee nor the health maintenance organization objects.(e) The enrollee shall not pay any of the costs associated with the services of an independent review organization under this chapter. All costs must be paid by the health maintenance organization.As added by P.L.133-1999, SEC.7. Amended by P.L.160-2011, SEC.29; P.L.81-2012, SEC.41.
IN Code § 27-13-10.1-3 (2021)
2021 Indiana Code|Title 27. Insurance|Article 13. Health Maintenance Organizations|Chapter 10.1. External Review of Grievances|27-13-10.1-3. Cooperation With Review Organization; Requirements of Enrollee

Sec. 3. (a) An enrollee who files an appeal under this chapter shall:(1) not be subject to retaliation for exercising the enrollee's right to an appeal under this chapter;(2) be permitted to utilize the assistance of other individuals, including physicians, attorneys, friends, and family members throughout the review process;(3) be permitted to submit additional information relating to the proposed service throughout the review process; and(4) cooperate with the independent review organization by:(A) providing any requested medical information; or(B) authorizing the release of necessary medical information.(b) A health maintenance organization shall cooperate with an independent review organization selected under section 2 of this chapter by promptly providing any information requested by the independent review organization.As added by P.L.133-1999, SEC.7.
IN Code § 27-13-10.1-4 (2021)
2021 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.
IN Code § 27-13-10.1-4.5 (2021)
2021 Indiana Code|Title 27. Insurance|Article 13. Health Maintenance Organizations|Chapter 10.1. External Review of Grievances|27-13-10.1-4.5. Information From Independent Review Organization

Sec. 4.5. Upon the request of an enrollee who is notified under section 4(c) of this chapter that the independent review organization has made a determination, the independent review organization shall provide to the enrollee all information reasonably necessary to enable the enrollee to understand the:(1) effect of the determination on the enrollee; and(2) manner in which the health maintenance organization may be expected to respond to the determination.As added by P.L.173-2007, SEC.43.
IN Code § 27-13-10.1-5 (2021)
2021 Indiana Code|Title 27. Insurance|Article 13. Health Maintenance Organizations|Chapter 10.1. External Review of Grievances|27-13-10.1-5. Determination Binding on Health Maintenance Organization

Sec. 5. A determination made under section 4 of this chapter is binding on the health maintenance organization.As added by P.L.133-1999, SEC.7.
IN Code § 27-13-10.1-6 (2021)
2021 Indiana Code|Title 27. Insurance|Article 13. Health Maintenance Organizations|Chapter 10.1. External Review of Grievances|27-13-10.1-6. Reconsideration of Resolution

Sec. 6. (a) If at any time during an external review performed under this chapter, the enrollee submits information to the health maintenance organization that is relevant to the health maintenance organization's resolution under IC 27-13-10-8 and was not considered by the health maintenance organization under IC 27-13-10:(1) the health maintenance organization shall reconsider the health maintenance organization's resolution under IC 27-13-10-8; and(2) the independent review organization shall cease the external review process until the reconsideration under subsection (b) is completed.(b) A health maintenance organization to which information is submitted under subsection (a) shall reconsider the resolution under IC 27-13-10-8 based on the information and notify the enrollee of the health maintenance organization's decision:(1) within seventy-two (72) hours after the information is submitted for a reconsideration related to an illness, a disease, a condition, an injury, or a disability that would seriously jeopardize the enrollee's:(A) life or health; or(B) ability to reach and maintain maximum function; or(2) within fifteen (15) days after the information is submitted for a reconsideration not described in subdivision (1).(c) If the decision reached under subsection (b) is adverse to the enrollee, the enrollee may request that the independent review organization resume the external review under this chapter.As added by P.L.133-1999, SEC.7.
IN Code § 27-13-10.1-7 (2021)
2021 Indiana Code|Title 27. Insurance|Article 13. Health Maintenance Organizations|Chapter 10.1. External Review of Grievances|27-13-10.1-7. Terms of Coverage Unchanged

Sec. 7. This chapter does not add to or otherwise change the terms of coverage included in a contract under which an enrollee receives health care benefits under IC 27-13.As added by P.L.133-1999, SEC.7.
IN Code § 27-13-10.1-9 (2021)
2021 Indiana Code|Title 27. Insurance|Article 13. Health Maintenance Organizations|Chapter 10.1. External Review of Grievances|27-13-10.1-9. Confidentiality

Sec. 9. Except as provided in section 8(g) of this chapter, documents and other information created or received by the independent review organization or the medical review professional in connection with an external review under this chapter:(1) are not public records;(2) may not be disclosed under IC 5-14-3; and(3) must be treated in accordance with confidentiality requirements of state and federal law.As added by P.L.133-1999, SEC.7.
IN Code § 27-13-10.1-10 (2021)
2021 Indiana Code|Title 27. Insurance|Article 13. Health Maintenance Organizations|Chapter 10.1. External Review of Grievances|27-13-10.1-10. Immunity From Civil Liability

Sec. 10. (a) An independent review organization is immune from civil liability for actions taken in good faith in connection with an external review under this chapter.(b) The work product or determination, or both, of an independent review organization under this chapter are admissible in a judicial or administrative proceeding. However, the work product or determination, or both, do not, without other supporting evidence, satisfy any party's burden of proof or persuasion concerning any material issue of fact or law.As added by P.L.133-1999, SEC.7.
IN Code § 27-13-10.1-11 (2021)
2021 Indiana Code|Title 27. Insurance|Article 13. Health Maintenance Organizations|Chapter 10.1. External Review of Grievances|27-13-10.1-11. Medicare Review

Sec. 11. If an enrollee has the right to an external review under Medicare (42 U.S.C. 1395 et seq.) the enrollee may not request an external review under this chapter.As added by P.L.133-1999, SEC.7.
IN Code § 27-13-10.1-12 (2021)
2021 Indiana Code|Title 27. Insurance|Article 13. Health Maintenance Organizations|Chapter 10.1. External Review of Grievances|27-13-10.1-12. Adoption of Rules

Sec. 12. The department may adopt rules under IC 4-22-2 to implement this chapter.As added by P.L.133-1999, SEC.7.
IN Code § 27-13-11-1 (2021)
2021 Indiana Code|Title 27. Insurance|Article 13. Health Maintenance Organizations|Chapter 11. Investments|27-13-11-1. Permitted Investments

Sec. 1. Except for investments under IC 27-13-4-1(a)(1), the funds of a health maintenance organization or limited service health maintenance organization may be invested only as follows:(1) The funds of a health maintenance organization or limited service health maintenance organization that is domiciled in Indiana may be invested only in the types of securities and other investments in which investment is authorized under IC 27-1-13-3.(2) The funds of a foreign corporation (as defined in IC 27-1-2-3) that obtains a certificate of authority to operate a health maintenance organization under IC 27-13-2-3 or a limited service health maintenance organization under IC 27-13-34-9 may be invested only in the types of securities and other investments in which investment is authorized:(A) under the law of the state in which the foreign corporation is domiciled, if that law is acceptable to the commissioner; or(B) under IC 27-1-13-3, if the law of the state in which the foreign corporation is domiciled is silent or if the law of that state is not acceptable to the commissioner.As added by P.L.26-1994, SEC.25.
IN Code § 27-13-12-1 (2021)
2021 Indiana Code|Title 27. Insurance|Article 13. Health Maintenance Organizations|Chapter 12. Protection Against Insolvency; Net Worth Requirements|27-13-12-1. "Net Worth" Defined; Computation

Sec. 1. (a) As used in this chapter, "net worth" means the excess of total assets over total liabilities, excluding liabilities that have been subordinated in a manner acceptable to the commissioner.(b) For the purposes of computing net worth, the total assets must be reduced by the value assigned to the following intangible assets:(1) Goodwill.(2) Going concern value.(3) Organizational expense.(4) Start-up costs.(5) Long term prepayments of deferred charges.(6) Nonreturnable deposits.(7) Obligations of officers, directors, owners, or affiliates, except short term obligations of affiliates for goods or services that:(A) arise in the normal course of business;(B) are payable on the same terms as equivalent transactions with nonaffiliates; and(C) are not past due.(c) For purposes of computing net worth, the health maintenance organization may include in its assets the value assigned to the following:(1) Medical equipment that:(A) is owned by the health maintenance organization and is not subject to any lien, claim, or encumbrance;(B) is used in the treatment, diagnosis, or care of enrollees of the health maintenance organization;(C) has an initial cost of at least three thousand dollars ($3,000) for each piece of equipment; and(D) has a useful life of at least two (2) years.(2) Data processing equipment that is:(A) owned by the health maintenance organization and is not subject to any lien, claim, or encumbrance; and(B) used in the operation of the health maintenance organization.(d) The value assigned to the assets described in subsection (c) must equal the lesser of:(1) the fair market value; or(2) the cost of the equipment, minus its accumulated depreciation, calculated in accordance with generally accepted accounting principles.(e) The aggregate value of the medical equipment described in subsection (c)(1) may not exceed thirty percent (30%) of the total assets permitted to be included in the computation of net worth.As added by P.L.26-1994, SEC.25. Amended by P.L.195-1996, SEC.6.
IN Code § 27-13-12-2 (2021)
2021 Indiana Code|Title 27. Insurance|Article 13. Health Maintenance Organizations|Chapter 12. Protection Against Insolvency; Net Worth Requirements|27-13-12-2. Initial Minimum Net Worth

Sec. 2. Before issuing a certificate of authority to a health maintenance organization, the commissioner shall require that the health maintenance organization:(1) have an initial net worth of at least one million five hundred thousand dollars ($1,500,000); and(2) maintain, after issuance of the certificate, at least the minimum net worth required under section 3 of this chapter.As added by P.L.26-1994, SEC.25.
IN Code § 27-13-12-3 (2021)
2021 Indiana Code|Title 27. Insurance|Article 13. Health Maintenance Organizations|Chapter 12. Protection Against Insolvency; Net Worth Requirements|27-13-12-3. Maintenance of Minimum Net Worth

Sec. 3. Except as provided in sections 4 and 5 of this chapter, a health maintenance organization shall maintain a minimum net worth equal to the greater of:(1) one million dollars ($1,000,000);(2) based on annual premium revenues as reported on the most recent annual financial statement filed with the commissioner, the total of two percent (2%) of annual premium revenues on the first one hundred fifty million dollars ($150,000,000) of premium and one percent (1%) of annual premium on the premium in excess of one hundred fifty million dollars ($150,000,000);(3) an amount equal to the sum of three (3) months of uncovered health care expenditures, as reported on the most recent financial statement of the health maintenance organization filed with the commissioner under IC 27-13-8-2(a)(1); or(4) an amount equal to the sum of:(A) eight percent (8%) of annual health care expenditures except those paid on a capitated basis or managed hospital payment basis as reported on the most recent financial statement filed with the commissioner; and(B) four percent (4%) of annual hospital expenditures paid on a managed hospital payment basis as reported on the most recent financial statement filed with the commissioner.As added by P.L.26-1994, SEC.25.
IN Code § 27-13-12-4 (2021)
2021 Indiana Code|Title 27. Insurance|Article 13. Health Maintenance Organizations|Chapter 12. Protection Against Insolvency; Net Worth Requirements|27-13-12-4. Net Worth Schedule

Sec. 4. A health maintenance organization licensed before July 1, 1994, must maintain a net worth equal to the following:(1) Twenty-five percent (25%) of the amount required under section 3 of this chapter by December 31, 1994.(2) Fifty percent (50%) of the amount required under section 3 of this chapter by December 31, 1995.(3) Seventy-five percent (75%) of the amount required under section 3 of this chapter by December 31, 1996.(4) One hundred percent (100%) of the amount required under section 3 of this chapter by December 31, 1997.As added by P.L.26-1994, SEC.25.
IN Code § 27-13-12-5 (2021)
2021 Indiana Code|Title 27. Insurance|Article 13. Health Maintenance Organizations|Chapter 12. Protection Against Insolvency; Net Worth Requirements|27-13-12-5. Consideration of Debts

Sec. 5. (a) In determining net worth under this chapter, a debt may not be considered fully subordinated unless:(1) the subordination clause is in a form acceptable to the commissioner; and(2) any interest obligation relating to the repayment of the subordinated debt is subordinated under a clause that is in a form acceptable to the commissioner.(b) The interest expense relating to the repayment of any fully subordinated debt is considered a covered expense.(c) Any debt that:(1) is incurred through a note that meets the requirements of this chapter; and(2) is otherwise acceptable to the commissioner;may not be considered liability and must be recorded as equity.As added by P.L.26-1994, SEC.25.