Indiana puts a board-certified specialist on the file

120 days, counted from the resolution

The request for external grievance review must be filed not more than 120 days after the covered individual is notified of the resolution of the internal grievance — and the start point, not the length, is what catches people. It runs from the resolution of the grievance, not from the original denial. Older summaries of Indiana law still circulate quoting 45 days; that was the pre-ACA text of IC 27-8-29 and it is not the current rule.

• The request is written, and it goes to the insurer rather than to the Department.
• The clock starts at notification of the internal grievance resolution, not at the original denial.
• A covered individual or their authorised representative may file it.

Who reads the file

Indiana is specific about the reviewer's credentials, and the specification is a strong one. The medical review professional assigned by the independent review organization must be board certified in the specialty in which the proposed service would be provided, must be knowledgeable about that service through actual clinical experience, must hold an unlimited licence to practise in a US state, and must have no history of disciplinary action or sanction.

• Board certified in the relevant specialty — not merely a licensed physician.
• Knowledgeable about the proposed service through actual clinical experience.
• Unlimited licence, and no disciplinary history.
• The Department certifies the organizations annually and makes the list available to insurers.

How fast the answer comes

• Standard external grievance: a determination within 15 business days.
• Expedited external grievance: within 72 hours.
• The reviewer decides on information gathered from the covered individual or designee, the insurer, and the treating provider — so the treating physician is a direct input, not a bystander.

Filing it

1. 1

   Finish the internal grievance

   The external review follows the insurer's internal grievance procedure under IC 27-8-28.

2. 2

   Note the resolution date

   That date starts the 120 days. Record it the moment the resolution notice arrives.

3. 3

   Send a written request to the insurer

   Indiana routes the request through the insurer, which then works from the Department's certified list of review organizations.

4. 4

   Get the treating provider's input in

   The reviewer gathers information from the treating health care provider as well as the parties, so a prepared clinical statement carries weight.

For Indiana practices

Two features shape how an Indiana submission should be written. The answer comes back in 15 business days, so there is no long stretch in which a reviewer might come back for more — whatever is in the file is what gets read. And that reader is board certified in the specialty at issue, which raises the useful ceiling on how technical the argument can be: the criteria, the imaging and the failed alternatives will land with someone who performs the service rather than with a generalist.

If the plan is a self-funded employer plan

None of the above applies to a self-funded ERISA plan, which is not subject to Indiana insurance law and follows the federal external-review route instead. Confirm which kind of coverage produced the denial before starting any count, because the two frameworks measure from different documents — Indiana from the resolution of the internal grievance, the federal process from the final internal adverse determination.