760 Ind. Admin. Code 1-59-14
Current through December 12, 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: |
760 IAC 1-59-14