§ 27-1-37.5-1 Application of chapter
§ 27-1-37.5-1.5 “Adverse determination”
§ 27-1-37.5-1.7 “Clinical peer”
§ 27-1-37.5-2 “Covered individual”
§ 27-1-37.5-3 “CPT code”
§ 27-1-37.5-4 “Health care service”
§ 27-1-37.5-5 “Health plan”
§ 27-1-37.5-6 “Participating provider”
§ 27-1-37.5-7 “Prior authorization”
§ 27-1-37.5-8 “Urgent care situation”
§ 27-1-37.5-9 Availability of prior authorization information; requirements; new requirements; address change; notices
§ 27-1-37.5-10 Request for prior authorization; electronic transmission; standardized form
§ 27-1-37.5-11 Response to request for prior authorization; timing; incomplete request
§ 27-1-37.5-12 Claim for which prior authorization was given; denial; resubmission of claim
§ 27-1-37.5-13 Unanticipated, medically necessary health care service; denial; payment for health care service with prior authorization
§ 27-1-37.5-13.5 State employee health plan prohibited from requiring prior authorization for certain CPT codes; retroactive denial; review of impact
§ 27-1-37.5-14 Contrary contract provision void
§ 27-1-37.5-15 Violation of chapter
§ 27-1-37.5-16 Department of insurance; standardized prior authorization form
§ 27-1-37.5-17 Peer to peer review; request
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Terms Used In Indiana Code > Title 27 > Article 1 > Chapter 37.5 - Health Care Service Prior Authorization

  • adverse determination: means a denial of a request for benefits on the grounds that the health service or item:

    Indiana Code 27-1-37.5-1.5

  • clinical peer: means a practitioner or other health care provider who either:

    Indiana Code 27-1-37.5-1.7

  • Commissioner: means the "insurance commissioner" of this state. See Indiana Code 27-1-2-3
  • Contract: A legal written agreement that becomes binding when signed.
  • covered individual: means an individual who is covered under a health plan. See Indiana Code 27-1-37.5-2
  • CPT code: refers to the medical billing code that applies to a specific health care service, as published in the Current Procedural Terminology code set maintained by the American Medical Association. See Indiana Code 27-1-37.5-3
  • Department: means "the department of insurance" of this state. See Indiana Code 27-1-2-3
  • Dependent: A person dependent for support upon another.
  • health care service: means a health care related service or product rendered or sold by a health care provider within the scope of the health care provider's license or legal authorization, including hospital, medical, surgical, mental health, and substance abuse services or products. See Indiana Code 27-1-37.5-4
  • health plan: means any of the following that provides coverage for health care services:

    Indiana Code 27-1-37.5-5

  • in writing: include printing, lithographing, or other mode of representing words and letters. See Indiana Code 1-1-4-5
  • Insurance: means a contract of insurance or an agreement by which one (1) party, for a consideration, promises to pay money or its equivalent or to do an act valuable to the insured upon the destruction, loss or injury of something in which the other party has a pecuniary interest, or in consideration of a price paid, adequate to the risk, becomes security to the other against loss by certain specified risks; to grant indemnity or security against loss for a consideration. See Indiana Code 27-1-2-3
  • insurer: means a company, firm, partnership, association, order, society or system making any kind or kinds of insurance and shall include associations operating as Lloyds, reciprocal or inter-insurers, or individual underwriters. See Indiana Code 27-1-2-3
  • Jurisdiction: (1) The legal authority of a court to hear and decide a case. Concurrent jurisdiction exists when two courts have simultaneous responsibility for the same case. (2) The geographic area over which the court has authority to decide cases.
  • participating provider: refers to the following:

    Indiana Code 27-1-37.5-6

  • person: includes individuals, corporations, associations, and partnerships; personal pronoun includes all genders; the singular includes the plural and the plural includes the singular. See Indiana Code 27-1-2-3
  • prior authorization: means a practice implemented by a health plan through which coverage of a health care service is dependent on the covered individual or health care provider obtaining approval from the health plan before the health care service is rendered. See Indiana Code 27-1-37.5-7
  • United States: includes the District of Columbia and the commonwealths, possessions, states in free association with the United States, and the territories. See Indiana Code 1-1-4-5
  • urgent care situation: means a situation in which a covered individual's treating physician has determined that the covered individual's condition is likely to result in:

    Indiana Code 27-1-37.5-8