Sec. 17. (a) As used in this section, “necessary information” includes the results of any face-to-face clinical evaluation, second opinion, or other clinical information that is directly applicable to the requested service that may be required.

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Terms Used In Indiana Code 27-1-37.5-17

  • 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

  • covered individual: means an individual who is covered under a health plan. See Indiana Code 27-1-37.5-2
  • 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
  • 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) If a health plan makes an adverse determination on a prior authorization request by a covered individual‘s health care provider, the health plan must offer the covered individual’s health care provider the option to request a peer to peer review by a clinical peer concerning the adverse determination.

     (c) A covered individual’s health care provider may request a peer to peer review by a clinical peer either in writing or electronically.

     (d) If a peer to peer review by a clinical peer is requested under this section:

(1) the health plan’s clinical peer and the covered individual’s health care provider or the health care provider’s designee shall make every effort to provide the peer to peer review not later than seven (7) business days from the date of receipt by the health plan of the request by the covered individual’s health care provider for a peer to peer review if the health plan has received the necessary information for the peer to peer review; and

(2) the health plan must have the peer to peer review conducted between the clinical peer and the covered individual’s health care provider or the provider’s designee.

As added by P.L.190-2023, SEC.18.

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