Sec. 10. (a) This section applies to a request for prior authorization delivered to a health plan after December 31, 2019.

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Terms Used In Indiana Code 27-1-37.5-10

  • Commissioner: means the "insurance commissioner" of this state. See Indiana Code 27-1-2-3
  • covered individual: means an individual who is covered under a health plan. See Indiana Code 27-1-37.5-2
  • Department: means "the department of insurance" of this state. See Indiana Code 27-1-2-3
  • health plan: means any of the following that provides coverage for health care services:

    Indiana Code 27-1-37.5-5

  • 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
     (b) A health plan shall accept a request for prior authorization delivered to the health plan by a covered individual‘s health care provider through a secure electronic transmission. A health care provider shall submit a request for prior authorization through a secure electronic transmission. A health plan shall provide for:

(1) a secure electronic transmission; and

(2) acknowledgment of receipt, by use of a transaction number or another reference code;

of a request for prior authorization and any supporting information.

     (c) Subsection (b) does not apply and a health plan that requires prior authorization shall accept a request for prior authorization that is not submitted through a secure electronic transmission if a covered individual’s health care provider and the health plan have entered into an agreement under which the health plan agrees to process prior authorization requests that are not submitted through a secure electronic transmission because:

(1) secure electronic transmission of prior authorization requests would cause financial hardship for the health care provider;

(2) the area in which the health care provider is located lacks sufficient Internet access; or

(3) the health care provider has an insufficient number of covered individuals as patients or customers, as determined by the commissioner, to warrant the financial expense that compliance with subsection (b) would require.

     (d) If a covered individual’s health care provider is described in subsection (c), the health plan shall accept from the health care provider a request for prior authorization as follows:

(1) The prior authorization request must be made on the standardized prior authorization form established by the department under section 16 of this chapter.

(2) The health plan shall provide for secure electronic transmission and acknowledgement of receipt of the standardized prior authorization form and any supporting information for the prior authorization by use of a transaction number or another reference code.

As added by P.L.77-2018, SEC.2. Amended by P.L.208-2018, SEC.8.

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