760 IAC 1-59-14 Grievance procedures report form

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 Number Of Days 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: