2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 10.1. External Review of Grievances › 27-13-10.1-8. Certification of Independent Review Organizations

Sec. 8. (a) The department shall establish and maintain a process for annual certification of independent review organizations.
(b) The department shall certify a number of independent review organizations determined by the department to be sufficient to fulfill the purposes of this chapter.
(c) An independent review organization shall meet the following minimum requirements for certification by the department:
(1) Medical review professionals assigned by the independent review organization to perform external grievance reviews under this chapter:
(A) must be board certified in the specialty in which an enrollee's proposed service would be provided;
(B) must be knowledgeable about a proposed service through actual clinical experience;
(C) must hold an unlimited license to practice in a state of the United States; and
(D) must have no history of disciplinary actions or sanctions including:
(i) loss of staff privileges; or
(ii) restriction on participation;
taken or pending by any hospital, government, or regulatory body.
(2) The independent review organization must have a quality assurance mechanism to ensure the:
(A) timeliness and quality of reviews;
(B) qualifications and independence of medical review professionals;
(C) confidentiality of medical records and other review materials; and
(D) satisfaction of enrollees with the procedures utilized by the independent review organization, including the use of enrollee satisfaction surveys.
(3) The independent review organization must file with the department the following information before March 1 of each year:
(A) The number and percentage of determinations made in favor of enrollees.
(B) The number and percentage of determinations made in favor of health maintenance organizations.
(C) The average time to process a determination.
(D) The number of external grievance reviews terminated due to reconsideration of the health maintenance organization before a determination was made.
(E) Any other information required by the department.
The information required under this subdivision must be specified for each health maintenance organization for which the independent review organization performed reviews during the reporting year.
(4) The independent review organization must retain all records related to an external grievance review for at least three (3) years after a determination is made under section 4 of this chapter.
(5) Any additional requirements established by the department.
(d) The department may not certify an independent review organization that is one (1) of the following:
(1) A professional or trade association of health care providers or a subsidiary or an affiliate of a professional or trade association of health care providers.
(2) A health insurer, health maintenance organization, or health plan association or a subsidiary or an affiliate of a health insurer, health maintenance organization, or health plan association.
(e) The department may suspend or revoke an independent review organization's certification if the department finds that the independent review organization is not in substantial compliance with the certification requirements under this section.
(f) The department shall make available to health maintenance organizations a list of all certified independent review organizations.
(g) The department shall make the information provided to the department under subsection (c)(3) available to the public in a format that does not identify individual enrollees.
As added by P.L.133-1999, SEC.7. Amended by P.L.14-2000, SEC.60; P.L.160-2011, SEC.30.