Sec. 15. (a) An independent review organization shall:
(1) for an expedited external grievance filed under section 13(a)(2)(A) of this chapter, within seventy-two (72) hours after the external grievance is filed; or
(2) for a standard external grievance filed under section 13(a)(2)(B) of this chapter, within fifteen (15) business days after the external grievance is filed;
make a determination to uphold or reverse the insurer's appeal resolution under IC 27-8-28-17 based on information gathered from the covered individual or the covered individual's designee, the insurer, and the treating health care provider, and any additional information that the independent review organization considers necessary and appropriate.
(b) When making the determination under this section, the independent review organization shall apply:
(1) standards of decision making that are based on objective clinical evidence; and
(2) the terms of the covered individual's accident and sickness insurance policy.
(c) In an external grievance described in section 12(1)(D) of this chapter, the insurer bears the burden of proving that the insurer properly denied coverage for a condition, complication, service, or treatment because the condition, complication, service, or treatment is directly related to a condition for which coverage has been waived under IC 27-8-5-2.5(e) (expired July 1, 2007, and removed) or IC 27-8-5-19.2 (expired July 1, 2007, and repealed).
(d) The independent review organization shall notify the insurer and the covered individual of the determination made under this section:
(1) for an expedited external grievance filed under section 13(a)(2)(A) of this chapter, within seventy-two (72) hours after the external grievance is filed; and
(2) for a standard external grievance filed under section 13(a)(2)(B) of this chapter, within seventy-two (72) hours after making the determination.
As added by P.L.66-2001, SEC.3 and P.L.203-2001, SEC.14. Amended by P.L.211-2003, SEC.9; P.L.3-2008, SEC.218; P.L.81-2012, SEC.37; P.L.72-2016, SEC.21.
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