Indiana Administrative Code › Title 760 - DEPARTMENT OF INSURANCE › Article 1 - GENERAL PROVISIONS › Rule 59 - HMO Grievance Procedures › Section 59-14 - Grievance procedures report form

Current through July 10, 2024
Authority: IC
				  27-13-10-13; IC
				  27-13-35-1
Affected: IC
				  27-13-8-2
Sec. 14.
The form required by section 4(a) of this rule is the
				  following:
GRIEVANCE PROCEDURES REPORT
NAME: _______________________________
FOR REPORTING PERIOD January 1, ____ through December 31,
				  ____
Block 1 REPORTING COMPANY INFORMATION
NAIC Group Code:
Assumed business name(s):
Address:
General business telephone number:
Grievance reporting - toll free
							 number:
Name, telephone number, and e-mail address of
							 contact person for grievance procedures:
Languages in which grievances may be
							 filed:
Total number of Indiana enrollees at beginning of
							 reporting period:
Total number of Indiana enrollees at end of
							 reporting period:
Service area (use applicable county codes; if the
							 entire state, please indicate entire state rather than list all county
							 codes):
Block 2 GENERAL INFORMATION
Number of grievances filed
Number
							 of appeals filed
Number of grievances resolved
Number of appeals resolved
Number of grievances resolved with Company position
							 upheld
Number of appeals resolved with position
							 upheld
Number of grievances resolved with Company position
							 overturned
Number of appeals resolved with Company position
							 overturned
Number of grievances pending
Number of appeals pending
Time to resolve grievances (average number of
							 days)
Time to resolve appeals (average number of
							 days)
INTERNAL GRIEVANCE AND APPEALS INFORMATION
Block 3 NOTE: A grievance should not be recorded in more than
				  one (1) category.
Basis
Number Filed
Company
							 Position Upheld? Yes (#): No (#):
Number Pending
Average
							 Number Of Days To Resolve
Appealed ? Yes (#): No (#):
Company
							 Position Upheld On Appeal? Yes (#): No (#):
Number Of Appeals
							 Pending
Average Number Of Days To Resolve Appeals
DENIAL OR LIMITATION OF COVERED HEALTH
							 CARE SERVICES
Inpatient
							 services
Outpatient
							 services
Emergency
							 services
Mental or behavioral
							 services
Home health
							 care
Prescription
							 drugs
Equipment or
							 supplies
Laboratory
							 services
Experimental
							 treatments
Other
							 services
HEALTH CARE PROVIDERS (for HMOs, LSHMOs,
							 and Insurers with Network plans)
Quality of health care
							 services
No referral or expired
							 referral
Problem with particular provider not
							 available
Problem with number of providers
							 available
Problem with type of providers
							 available
Problem with provider
							 location
Problem getting
							 appointment
OTHER BASIS FOR GRIEVANCE
Difficulty in enrolling/ other enrollment
							 issues
Problem with claim payment or
							 handling
Benefits limited or
							 excluded
Timeliness of decision
							 making
Other (attach additional sheets if
							 necessary)
Block 4 DESCRIPTION OF GRIEVANCE PROCEDURES
Please describe your grievance procedures.
							 Attach additional sheets as necessary:
Block 5 DESCRIPTION OF APPEALS PROCEDURES
Please describe your appeals procedures.
							 Attach additional sheets as necessary: