Section 760 IAC 1-49-4 - General standards of medical claims reviewAuthority: IC 27-8-16-14
Affected: IC 27-8-16
Sec. 4. The medical claims review, including appeal requirements, shall be conducted in accordance with standards or guidelines developed with input from appropriate health care providers and approved by a physician. The medical claims review shall include the following components:
(1) Written procedures for the following: (A) Notification to the insurance companies, health maintenance organizations, or other benefit programs of the medical claims review agent's determinations.(B) Appeal of an adverse determination and a copy of any forms used during the appeal process, as required by section 6 of this rule.(C) Receiving or redirecting toll free telephone calls during normal business hours and after hour calls, either in person or by recording, and assurance that a toll free number will be maintained forty (40) hours per week during normal business hours, as addressed in section 7 of this rule.(D) Reviewing, including the following: (i) Any form used during the review process.(ii) Time frames that shall be met during the review.(E) Handling of written complaints by enrollees, patients, or health care providers as addressed in section 9(a) of this rule.(F) Determining if health care providers utilized by the medical claims review agents are licensed.(G) Orientation and training of personnel who perform medical claims review.(H) Assuring that patient-specific information obtained during the process of medical claims review, as addressed in section 8 of this rule, will be:(i) kept confidential in accordance with applicable federal and state laws;(ii) used for purposes of medical claims review, quality assurance, discharge planning, and catastrophic case management;(iii) shared with only those agencies (such as the claims administrator) that have authority to receive such information; and(iv) summary data shall not be considered confidential if it does not provide sufficient information to allow for identification of individual patients.(2) Each medical claims review agent shall utilize written screening criteria and review procedures that are established and periodically evaluated and updated with appropriate involvement from health care providers. Such written screening criteria and review procedures shall be available for review and inspection by the commissioner or a designated department of insurance representative and copying, as necessary, for the commissioner to carry out his or her lawful duties under the Insurance Code, provided; however, that any information obtained or acquired under the authority of this rule and IC 27-8-16 is confidential and privileged and not subject to the open records law or subpoena except to the extent necessary for the commissioner to enforce this rule and IC 27-8-16.(3) Medical claims review agents' decisions shall be made in accordance with standards or guidelines that are developed with input from appropriate health care providers and approved by a physician.Department of Insurance; 760 IAC 1-49-4; filed Dec 31, 1992, 9:00 a.m.: 16 IR 1397; readopted filed Sep 14, 2001, 12:22 p.m.: 25 IR 531; readopted filed Nov 27, 2007, 4:01 p.m.: 20071226-IR-760070717RFA; readopted filed November 26, 2013, 3:43 p.m.: 20131225-IR-760130479RFAReadopted filed 11/19/2019, 9:18 a.m.: 20191218-IR-760190497RFA