Indiana § 27-13-8-2 - Filings with commissioner; complaint analysis and reporting

§ 27-13-8-2. Filings with commissioner; complaint analysis and reporting

Sec. 2. (a) In addition to the report required by section 1 of this chapter, a health maintenance organization shall each year file with the commissioner the following:

(1) Audited financial statements of the health maintenance organization for the preceding calendar year prepared in conformity with statutory accounting practices prescribed or otherwise permitted by the department.

(2) A list of participating providers who provide health care services to enrollees or subscribers of the health maintenance organization.

(3) A description of the grievance procedure of the health maintenance organization:

(A) established under IC 27-13-10, including:

(i) the total number of grievances handled through the procedure during the preceding calendar year;

(ii) a compilation of the causes underlying those grievances; and

(iii) a summary of the final disposition of those grievances; and

(B) established under IC 27-13-10.1, including:

(i) the total number of external grievances handled through the procedure during the preceding calendar year;

(ii) a compilation of the causes underlying those grievances; and

(iii) a summary of the final disposition of those grievances;

for each independent review organization used by the health maintenance organization during the reporting year.

(4) The percentage of providers credentialed by the health maintenance organization according to the National Committee on Quality Assurance standards or guidelines.

(5) The RBC report required under IC 27-1-36-25.

(6) The health maintenance organization's Health Plan Employer Data and Information Set (HEDIS) data.

(b) The information required by subsection (a)(2) through (a)(5) must be filed with the commissioner on or before March 1 of each year. The audited financial statements required by subsection (a)(1) must be filed with the commissioner on or before June 1 of each year. The health maintenance organization's HEDIS data required by subsection (a)(6) must be filed with the commissioner on or before July 1 of each year. The commissioner shall:

(1) make the information required to be filed under this section available to the public; and

(2) prepare an annual compilation of the data required under subsection (a)(3), (a)(4), and (a)(6) that allows for comparative analysis.

(c) Upon a determination by a health maintenance organization's auditor that the health maintenance organization:

(1) does not meet the requirements of IC 27-13-12-3; or

(2) is in the condition described in IC 27-13-24-1(a)(5);

the health maintenance organization shall notify the commissioner within five (5) business days after the auditor's determination.

(d) The commissioner may require any additional reports as are necessary and appropriate for the commissioner to carry out the commissioner's duties under this article.

(e) The commissioner shall do the following:

(1) Compile and analyze complaints received by the department concerning a denial of coverage under an individual contract or a group contract for:

(A) an investigational or experimental treatment; or

(B) a treatment not considered to be medically necessary for an enrollee.

(2) If the commissioner determines that a pattern of denials of coverage is evident through the analysis performed under subdivision (1), report the pattern to the legislative council in an electronic format under IC 5-14-6.

(3) Remove from a report made under subdivision (2) any information that could be used to identify an individual.

As added by P.L.26-1994, SEC.25. Amended by P.L.195-1996, SEC.5; P.L.191-1997, SEC.2; P.L.133-1999, SEC.1; P.L.133-1999, SEC.2; P.L.203-2001, SEC.21; P.L.51-2002, SEC.10; P.L.18-2016, SEC.4; P.L.124-2018, SEC.92.