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Application Requirements for Registration of Medical Claims Review Agent are provided by IDOI.
The following items must be submitted in order to obtain a license. Please number each item in the upper right-hand corner to correspond with its number in this Schedule of Requirements.
1. Each application question must be completed in full. Attach a separate sheet of paper, properly signed, if additional space is needed.
2. Application attachments, which include Medical Claims Review checklist and supporting documentation. Complete the “Located” column on the checklist with section and page number of your submission indicating where the item can be found.
3. URAC accreditation does not waive any requirement for documentation submission.
4. Medical claims review plan summary including written screening criteria and review procedures.
5. Toll-free telephone number, hours of operation, contact person and phone number.
6. Confidentiality procedure.
7. Orientation and training of personnel and categories of persons employed for medical review.
8. Statement from a licensed physician that determinations are reviewed with standards and guidelines approved by a licensed physician.
9. Copy of procedures and forms used for notification of determination as per IC 27-8-16-7(7).
10. Signed statement as to your cooperation with the Department of Insurance on investigation of complaints made to the Department.
11. Signed statement that you are in compliance with IC 27-8-16-11 and IC 27-8-16.
12. EIN or FIN number.
13. A renewal fee of $100 will be invoiced during the month of May. Payment should be made in accordance with the invoice instructions and mailed to the post office box address.
Please submit your renewal fee with the application material.
The completed application and information requested above should be sent to the following:
Indiana Department of Insurance
Attn: Medical Claims Review
311 West Washington Street, Ste 300
Indianapolis, Indiana 46204