IN.gov - Skip Navigation

Note: This message is displayed if (1) your browser is not standards-compliant or (2) you have you disabled CSS. Read our Policies for more information.

Indiana Department of Insurance

IDOI > Financial Services > Initial Registration Requirements > Medical Claims Review > Rule 49. Registration of Medical Claims Review Agents Rule 49. Registration of Medical Claims Review Agents

IAC 760-1-49-1
760 IAC 1-49-1 Authority
Authority: IC 27-8-16-14
Affected: IC 27-8-16-14

Sec. 1. This rule is adopted and promulgated by the department of insurance under IC 27-8-16-14. (Department of Insurance; 760 IAC 1-49-1; filed Dec 31, 1992, 9:00 a.m.: 16 IR 1395)

IAC 760-1-49-2
760 IAC 1-49-2 Definitions
Authority: IC 27-8-16-14
Affected: IC 27-8-16

Sec. 2. The definitions in IC 27-8-16 shall apply to all provisions contained in this rule. (Department of Insurance; 760 IAC 1-49-2; filed Dec 31, 1992, 9:00 a.m.: 16 IR 1395)

IAC 760-1-49-3
760 IAC 1-49-3 Certification of medical claims review agents
Authority: IC 27-8-16-14
Affected: IC 4-21.5; IC 27-8-16-11

Sec. 3.

  1. An application for certification of a medical claims review agent must be filed with the department of insurance at 311 West Washington Street, Suite 300, Indianapolis, Indiana 46204. Initial applications must be filed on or before February 28, 1993.
  2. The application, and fees as addressed in section 11 of this rule, must be submitted on a medical claims review agent application form that can be obtained from the department of insurance. The application form is adopted by reference and may be obtained from the Department of Insurance, 311 West Washington Street, Suite 300, Indianapolis, Indiana 46204.
  3. The completed application form shall be accompanied by a summary of the following information:
    1. Procedures established for appeal of an adverse determination. These procedures must comply with section 6 of this rule.
    2. Policies and procedures that ensure that all applicable state and federal laws to protect the confidentiality of medical records are followed. These procedures must comply with section 8 of this rule.
  4. The completed application form shall contain the following information:
    1. A certification that the medical claims review agent will comply with the provisions of IC 27-8-16.
    2. The categories of persons employed to perform medical claims review. Personnel changes within the categories do not constitute a material change in the application.
    3. A description of the hours of operation within the state of Indiana and how the medical claims review agent may be contacted during weekends and holidays. This description must be in compliance with section 7 of this rule.
    4. Representative samples of materials provided by the medical claims review agent or applicant to inform its clients, enrollees, or providers of the requirements of medical claims review.
    5. A certification that the medical claims review agent is in compliance with IC 27-8-16-11.
  5. The medical claims review agent shall report any material changes in the information in the application or renewal form referred to in this section not later than the thirtieth day after the date on which the change takes effect.
  6. The application process shall be as follows:
    1. The department of insurance shall have thirty (30) days after receipt of an application to determine whether the application is complete. In the event that an application is found to be incomplete, the department of insurance will give the applicant written notice of the required information necessary to complete the application. If the application is complete, the applicant will be advised that the application has been received and accepted for review.
    2. The department of insurance shall have sixty (60) days from the date the application is determined to be complete under subdivision (1) to process the application and approve or disapprove it. The department of insurance shall give the applicant written notice of any deficiencies noted as a result of the review conducted under this subdivision.
    3. The department of insurance shall afford the applicant an opportunity for a meeting to discuss any omissions or deficiencies noted.
    4. The applicant must correct the omissions or deficiencies in the application within thirty (30) days of the date of the latest notice of the department of insurance of such omissions or deficiencies. If the applicant fails to do so, the application file will be closed as an incomplete application. The application fee will not be refundable.
    5. The department of insurance shall maintain an application file that shall contain the application, notices of omissions or deficiencies, responses, and any written materials generated by any person who was considered by the department of insurance in evaluating the application.
  7. A medical claims review agent must apply for a certificate renewal every year, not later than June 30. The initial renewal shall be completed by June 30, 1994. A renewal form must be used for this purpose. The renewal fee must be submitted with the renewal form. The renewal form can be obtained from the department of insurance at the address listed in subsection (a). The completed renewal form and the renewal fee must be submitted to the department of insurance at the address listed in subsection (a). A medical claims review agent may continue to operate under its certificate after a completed renewal application form and the renewal fee have been timely received by the department of insurance until the renewal is finally denied or issued by the department of insurance. If a completed renewal application and fee are not received prior to June 30, the certificate will automatically be canceled, and the medical claims review agent must complete and submit a new application form with the new application fee for another certificate of registration.
  8. If an application or renewal is denied under this section, the applicant or registrant may appeal such denial under the terms of the provisions of IC 4-21.5. A hearing of such appeal shall be conducted within forty-five (45) days from the date the petition for hearing is filed with the commissioner. A decision by the commissioner shall be rendered within sixty (60) days from the date of the hearing.
  9. Applications that are filed on or before February 28, 1993, will be processed on a first in, first out basis by the department of insurance. The time lines set out for processing applications in subsection (f) will not apply to these applications.
  10. Entities that were operating in Indiana as medical claims review agents on or after July 1, 1992, must file the application described in subsections (a) through (d) by February 28, 1993. Those entities may continue to operate as medical claims review agents pending review of the application unless they are advised in writing that the application has been disapproved or closed as an incomplete application as described in subsection (f). No entity may continue to operate after fifteen (15) days from the date of the notice of the denial or closure of the file. (Department of Insurance; 760 IAC 1-49-3; filed Dec 31, 1992, 9:00 a.m.: 16 IR 1395)

IAC 760-1-49-4
760 IAC 1-49-4 General standards of medical claims review
Authority: IC 27-8-16-14
Affected: IC 27-8-16

Sec. 4. The medical claims review, including appeal requirements, shall be conducted in accordance with standards or guidelines developed with input from appropriate health care providers and approved by a physician. The medical claims review shall include the following components:

  1. Written procedures for the following:
    1. Notification to the insurance companies, health maintenance organizations, or other benefit programs of the medical claims review agent's determinations.
    2. Appeal of an adverse determination and a copy of any forms used during the appeal process, as required by section 6 of this rule.
    3. Receiving or redirecting toll free telephone calls during normal business hours and after hour calls, either in person or by recording, and assurance that a toll free number will be maintained forty (40) hours per week during normal business hours, as addressed in section 7 of this rule.
    4. Reviewing, including the following:
      1. Any form used during the review process.
      2. Time frames that shall be met during the review.
    5. Handling of written complaints by enrollees, patients, or health care providers as addressed in section 9(a) of this rule.
    6. Determining if health care providers utilized by the medical claims review agents are licensed.
    7. Orientation and training of personnel who perform medical claims review.
    8. Assuring that patient-specific information obtained during the process of medical claims review, as addressed in section 8 of this rule, will be:
      1. kept confidential in accordance with applicable federal and state laws;
      2. used for purposes of medical claims review, quality assurance, discharge planning, and catastrophic case management;
      3. shared with only those agencies (such as the claims administrator) that have authority to receive such information; and
      4. summary data shall not be considered confidential if it does not provide sufficient information to allow for identification of individual patients.
  2. Each medical claims review agent shall utilize written screening criteria and review procedures that are established and periodically evaluated and updated with appropriate involvement from health care providers. Such written screening criteria and review procedures shall be available for review and inspection by the commissioner or a designated department of insurance representative and copying, as necessary, for the commissioner to carry out his or her lawful duties under the Insurance Code, provided; however, that any information obtained or acquired under the authority of this rule and IC 27-8-16 is confidential and privileged and not subject to the open records law or subpoena except to the extent necessary for the commissioner to enforce this rule and IC 27-8-16.
  3. Medical claims review agents' decisions shall be made in accordance with standards or guidelines that are developed with input from appropriate health care providers and approved by a physician.

(Department of Insurance; 760 IAC 1-49-4; filed Dec 31, 1992, 9:00 a.m.: 16 IR 1397)

IAC 760-1-49-5
760 IAC 1-49-5 Notice of determinations made by medical claims review agents
Authority: IC 27-8-16-14
Affected: IC 27-8-16-7

Sec. 5. In making a determination as to reimbursement of a claim, medical claims review agents shall comply with all provisions contained in IC 27-8-16-7. (Department of Insurance; 760 IAC 1-49-5; filed Dec 31, 1992, 9:00 a.m.: 16 IR 1397)

IAC 760-1-49-6
760 IAC 1-49-6 Appeal of adverse determination of medical claims review agents
Authority: IC 27-8-16-14
Affected: IC 27-8-16-8

Sec. 6. A medical claims review agent shall comply with all provisions of IC 27-8-16-8 in establishing an appeal procedure for adverse determinations. (Department of Insurance; 760 IAC 1-49-6; filed Dec 31, 1992, 9:00 a.m.: 16 IR 1397)

IAC 760-1-49-7
760 IAC 1-49-7 Medical claims review agent's telephone access
Authority: IC 27-8-16-14
Affected: IC 27-8-16-7

Sec. 7.

  1. A medical claims review agent shall have personnel available by toll free telephone at least forty (40) hours per week during normal business hours.
  2. A medical claims review agent must have a telephone system capable of accepting, recording, or providing instructions to incoming calls during other than normal business hours and shall respond to such calls not later than two (2) working days after the date on which the call was received. (Department of Insurance; 760 IAC 1-49-7; filed Dec 31, 1992, 9:00 a.m.: 16 IR 1397)

IAC 760-1-49-8
760 IAC 1-49-8 Confidentiality
Authority: IC 27-8-16-14
Affected: IC 27-8-16

Sec. 8.

  1. A medical claims review agent shall preserve the confidentiality of individual medical records to the extent required by state and federal laws.
  2. To assure confidentiality, a medical claims review agent must, when contacting a health care provider's office or hospital, provide its certification number and the caller's name to the provider's named claim review agent representative in the health care provider's office.
  3. Medical records and patient-specific information shall be maintained by the medical claims review agent in a secure area with access limited to medical claims review personnel only.
  4. Information generated and obtained by the medical claims review agent or employer of the medical claims review agent in the course of medical claims review shall be retained for at least two (2) years if the information relates to a case for which an adverse decision was made at any point or if the information relates to a case that may be reopened. (Department of Insurance; 760 IAC 1-49-8; filed Dec 31, 1992, 9:00 a.m.: 16 IR 1398)

IAC 760-1-49-9
760 IAC 1-49-9 Complaints and information
Authority: IC 27-8-16-14
Affected: IC 27-8-16

Sec. 9.

  1. Within a reasonable time period, upon receipt of a written complaint alleging a violation of this section or IC 27-8-16 by a medical claims review agent, from an enrollee's health care provider, a person acting on behalf of the enrollee, or the enrollee, the commissioner or a designated department of insurance representative shall investigate the complaint and furnish a written response to the complainant and the medical claims review agent named. The response will not identify in any manner the patient or patients without written consent. This response must include the following:
    1. A statement of the original complaint.
    2. A copy of any written response by the medical claims review agent. The written response should not contain privileged medical records. If it is necessary to refer to medical records, they shall be forwarded separate from the response and clearly marked as privileged medical records.
    3. A statement of the findings of the commissioner or a designated department of insurance representative and an explanation of the basis of such findings.
    4. Corrective actions, if any, on the part of the medical claims review agent that the commissioner or a designated department of insurance representative finds appropriate.
    5. A time frame in which any corrective actions should be completed. The medical claims review agent will provide evidence of corrective action within the specified time frame to the commissioner or a designated department of insurance representative.
  2. In addition to the authority of the commissioner to respond to complaints described in subsection (a), the department of insurance is authorized to address inquiries to medical claims review agents that the department of insurance may deem necessary for the public good or for a proper discharge of its duties. It shall be the duty of the agent to promptly answer such inquiries in writing.
  3. The commissioner shall maintain and update a list of medical claims review agents issued certificates, including certificate numbers and the renewal date for those certificates. The commissioner shall provide the list at cost to all individuals or organizations requesting the list.
  4. Requirements for on-site review by the department of insurance shall be as follows:
    1. The commissioner or a designated department of insurance representative is authorized to make a complete on-site review of the operations of each medical claims review agent at the principal place of business for such agent as often as is deemed necessary.
    2. Medical claims review agents will be notified of the scheduled on-site visit by letter which will specify, as a minimum, the identity of the commissioner's designated department of insurance representative and the expected arrival date and time.
    3. The medical claims review agent must make available during such on-site visits all records relating to its operation.
    4. The commissioner or the designated department of insurance representative may perform periodic telephone audits of medical claims review agents authorized to conduct business in this state to determine if the agents are reasonably accessible.

(Department of Insurance; 760 IAC 1-49-9; filed Dec 31, 1992, 9:00 a.m.: 16 IR 1398; errata filed Feb 10, 1993, 4:00 p.m.: 16 IR 1514)

IAC 760-1-49-10
760 IAC 1-49-10 Administrative violations
Authority: IC 27-8-16-14
Affected: IC 27-8-16-12

Sec. 10. If the commissioner, through the commissioner's designated representative, believes that a medical claims review agent may have violated, or is violating, this section or IC 27-8-16, the commissioner's designated representative shall comply with IC 27-8-16-12 in investigating the complaint and, where appropriate, in imposing sanctions against the medical claims review agent. (Department of Insurance; 760 IAC 1-49-10; filed Dec 31, 1992, 9:00 a.m.: 16 IR 1398)

IAC 760-1-49-11
760 IAC 1-49-11 Fees
Authority: IC 27-8-16-5; IC 27-8-16-6; IC 27-8-16-14
Affected: IC 27-8-16-5; IC 27-8-16-6

Sec. 11.

  1. The fee for initial application for certification as a medical claims review agent is one hundred fifty dollars ($150) and must accompany the application.
  2. The annual renewal fee for a certificate as a medical claims review agent is one hundred dollars ($100) and must accompany the application. The annual renewal fee is nonrefundable. (Department of Insurance; 760 IAC 1-49-11; filed Dec 31, 1992, 9:00 a.m.: 16 IR 1399; filed Sep 5, 1996, 11:00 a.m.: 20 IR 16)