Ind. Admin. Code tit. 760, r. 1-59-14
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 NumberOfDays 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: | |
(Department of Insurance; 760 IAC 1-59-14; filed Sep 30, 1998, 2:17 p.m.: 22 IR 451, eff Jan 1, 1999; filed Feb 17, 2003, 9:57 a.m.: 26 IR 2331; readopted filed Nov 24, 2009, 9:35 a.m.: 20091223-IR-760090791RFA; readopted filed Nov 20, 2015, 9:25 a.m.: 20151216-IR-760150341RFA; readopted filed Nov 15, 2021, 8:32 a.m.: 20211215-IR-760210419RFA; readopted filed Oct 22, 2025, 3:17 p.m.: 20251119-IR-760240637RFA)