Policies and procedures for timely resolution of grievances

Sec. 16. (a) An insurer shall establish written policies and procedures for the timely resolution of grievances filed under this chapter. The policies and procedures must include the following: (1) An acknowledgment of the grievance, given orally or in writing, to the covered individual within five (5) business days after receipt of the grievance. (2) Documentation of the substance of the grievance and any actions taken. (3) An investigation of the substance of the grievance, including any aspects involving clinical care. (4) Notification to the covered individual of the disposition of the grievance and the right to appeal. (5) Standards for timeliness in: (A) responding to grievances; and (B) providing notice to covered individuals of: (i) the disposition of the grievance; and (ii) the right to appeal; that accommodate the clinical urgency of the situation. (b) An insurer shall appoint at least one (1) individual to resolve a grievance. (c) A grievance must be resolved as expeditiously as possible, but not more than twenty (20) business days after the insurer receives all information reasonably necessary to complete the review. If an insurer is unable to make a decision regarding the grievance within the twenty (20) day period due to circumstances beyond the insurer's control, the insurer shall: (1) before the twentieth business day, notify the covered individual in writing of the reason for the delay; and (2) issue a written decision regarding the grievance within an additional ten (10) business days. (d) An insurer shall notify a covered individual in writing of the resolution of a grievance within five (5) business days after completing an investigation. The grievance resolution notice must include the following: (1) A statement of the decision reached by the insurer. (2) A statement of the reasons, policies, and procedures that are the basis of the decision. (3) Notice of the covered individual's right to appeal the decision. (4) The department, address, and telephone number through which a covered individual may contact a qualified representative to obtain additional information about the decision or the right to appeal.