Indiana Code 27-8-17-12. Appeals procedure
(1) a written description of the appeals procedure by which an enrollee or a provider of record may appeal the utilization review determination by the utilization review agent; and
Terms Used In Indiana Code 27-8-17-12
- Appeal: A request made after a trial, asking another court (usually the court of appeals) to decide whether the trial was conducted properly. To make such a request is "to appeal" or "to take an appeal." One who appeals is called the appellant.
- Contract: A legal written agreement that becomes binding when signed.
- enrollee: means an individual who has contracted for or who participates in coverage under an insurance policy issued under insurance classes 1(b) and 2(a) of IC 27-1-5-1, health maintenance organization contract, or other benefit program providing payment, reimbursement, or indemnification for the costs of health care for:
Indiana Code 27-8-17-3
- health maintenance organization: has the meaning set forth in IC 27-13-1-19. See Indiana Code 27-8-17-4
- provider of record: means the physician or other licensed practitioner identified to a utilization review agent as having primary responsibility for the care, treatment, and services rendered to a covered individual. See Indiana Code 27-8-17-5
- utilization review: means a system for prospective, concurrent, or retrospective review of the medical necessity and appropriateness of health care services provided or proposed to be provided to a covered individual. See Indiana Code 27-8-17-6
- utilization review agent: means any entity performing utilization review, except the following:
Indiana Code 27-8-17-7
- utilization review determination: means the rendering of a decision based on utilization review that denies or affirms either of the following:
Indiana Code 27-8-17-8
(b) The appeals procedure provided by a utilization review agent must meet the following requirements:
(1) On appeal, the determination not to certify an admission, a service, or a procedure as necessary or appropriate must be made by a health care provider licensed in the same discipline as the provider of record.
(2) The determination of the appeal of a utilization review determination not to certify an admission, service, or procedure must be completed within thirty (30) days after:
(A) the appeal is filed; and
(B) all information necessary to complete the appeal is received.
(c) A utilization review agent shall provide an expedited appeals process for emergency or life threatening situations. The determination of an expedited appeal under the process required by this subsection shall be made by a physician and completed within forty-eight (48) hours after:
(1) the appeal is initiated; and
(2) all information necessary to complete the appeal is received by the utilization review agent.
(d) If an enrollee is covered under an accident and sickness insurance policy (as defined in IC 27-8-28-1) or a contract issued by a health maintenance organization (as defined in IC 27-13-1-19), the enrollee’s exclusive right to appeal a utilization review determination is provided under IC 27-8-28 or IC 27-13-10, respectively.
(e) A utilization review agent shall make available upon request a written description of the appeals procedure that an enrollee or provider of record may use to obtain a review of a utilization review determination by the utilization review agent.
As added by P.L.128-1992, SEC.1. Amended by P.L.66-2001, SEC.1; P.L.203-2001, SEC.12; P.L.1-2002, SEC.112.