Section 405 IAC 1-1.6-3 - Formal appeal to managed care organizationAuthority: IC 12-15-1-10; IC 12-15-21-2; IC 12-15-21-3
Affected: IC 12-15
Sec. 3.
(a) In the event the matter is not resolved to the provider's satisfaction within thirty (30) days after the provider commenced the informal process set out in section 2 of this rule, the provider shall have sixty (60) days after the end of the thirty (30) day period to submit a formal appeal notice to the MCO.(b) The provider's claim appeal notice must be in writing and specify the basis of the provider's dispute with the MCO.(c) The formal claim appeal procedure is commenced by the MCO's receipt of the provider's written claim appeal notice. The appeal review is conducted by a panel of one (1) or more individuals selected by the MCO. The panel shall: (1) be knowledgeable about the policy, legal, and clinical issues involved in the matter subject to the appeal;(2) not include an individual who has been involved in any previous consideration of the matter; and(3) consider all information and material submitted to it by the provider that bears directly upon an issue involved in the matter.(d) The MCO shall allow the provider an opportunity to appear in person before the panel or to communicate with the panel through appropriate other means if the provider is unable to appear in person.(e) The provider may be represented by an attorney or other representative during the formal claim appeal procedure.(f) The MCO's medical director, or other licensed physician designated by the medical director, shall serve as a consultant to the panel in the event the matter involves a question of medical necessity or medical appropriateness.(g) The panel shall make a written determination of the matter that is the subject of the provider's appeal. The panel's written determination of the matter shall: (1) be the MCO's final position in regard to the matter;(2) include, as applicable, a detailed explanation of the factual, legal, policy, and clinical basis of the panel's determination; and(3) include notice to the provider of the provider's right to submit to binding arbitration, or other binding resolution procedure to which the MCO and provider mutually agree, the matter that was the subject of the formal claim resolution procedure.(h) The panel's written determination shall be issued to the provider within forty-five (45) days after the commencement of the formal claim appeal process. In the event the panel fails to issue the panel's written determination within forty-five (45) days after the commencement of the formal claim appeal process, the failure on the part of the panel shall have the effect of an approval by the panel of the provider's claim.Office of the Secretary of Family and Social Services; 405 IAC 1-1.6-3; filed Nov 10, 2004, 3:15 p.m.: 28 IR 816; readopted filed Sep 19, 2007, 12:16p.m.: 20071010-IR-405070311RFA; readopted filed Oct 28, 2013, 3:18 p.m.: 20131127-IR-405130241RFAReadopted filed 11/13/2019, 11:54 a.m.: 20191211-IR-405190487RFAReadopted filed 5/30/2023, 11:54 a.m.: 20230628-IR-405230292RFA