Sec. 11. (a) This section applies to a prior authorization request delivered to a health plan after December 31, 2019.

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Terms Used In Indiana Code 27-1-37.5-11

  • 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
  • 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

     (b) A health plan shall respond to a request delivered under section 10 of this chapter as follows:

(1) If the request is delivered under section 10(b) of this chapter, the health plan shall immediately send to the requesting health care provider an electronic receipt for the request.

(2) If the request is for an urgent care situation, the health plan shall respond with a prior authorization determination not more than forty-eight (48) hours after receiving the request.

(3) If the request is for a nonurgent care situation, the health plan shall respond with a prior authorization determination not more than five (5) business days after receiving the request.

     (c) If a request delivered under section 10 of this chapter is incomplete:

(1) the health plan shall respond within the period required by subsection (b) and indicate the specific additional information required to process the request;

(2) if the request was delivered under section 10(b) of this chapter, upon receiving the response under subdivision (1), the health care provider shall immediately send to the health plan an electronic receipt for the response made under subdivision (1); and

(3) if the request is for an urgent care situation, the health care provider shall respond to the request for additional information not more than forty-eight (48) hours after the health care provider receives the response under subdivision (1).

     (d) If a request delivered under section 10 of this chapter is denied, the health plan shall respond within the period required by subsection (b) and indicate the specific reason for the denial in clear and easy to understand language.

As added by P.L.77-2018, SEC.2. Amended by P.L.190-2023, SEC.16.

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