Indiana Code 27-8-17-11. Minimum utilization review agent requirements
(1) Provide toll free telephone access at least forty (40) hours each week during normal business hours.
Terms Used In Indiana Code 27-8-17-11
- 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.
- department: refers to the department of insurance. See Indiana Code 27-8-17-2
- 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
- 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
- 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
- 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
(3) Respond to each telephone call left on the recording system maintained under subdivision (2) within two (2) business days after receiving the call.
(4) Protect the confidentiality of the medical records of covered individuals.
(5) Within two (2) business days after receiving a request for a utilization review determination that includes all information necessary to complete the utilization review determination, notify the enrollee or the provider of record of the utilization review determination by mail or another means of communication.
(6) Include in the notification of a utilization review determination not to certify an admission, a service, or a procedure:
(A) if the determination not to certify is based on medical necessity or appropriateness of the admission, service, or procedure, the principal reason for that determination; and
(B) the procedures to initiate an appeal of the determination.
(7) Ensure that every utilization review determination as to the necessity or appropriateness of an admission, a service, or a procedure is:
(A) reviewed by a physician; or
(B) determined in accordance with standards or guidelines approved by a physician.
(8) Ensure that every physician making a utilization review determination for the utilization review agent has a current license issued by a state licensing agency in the United States.
(9) Provide a period of at least forty-eight (48) hours following an emergency admission, service, or procedure during which:
(A) an enrollee; or
(B) the representative of an enrollee;
may notify the utilization review agent and request certification or continuing treatment for the condition involved in the admission, service, or procedure.
(10) Provide an appeals procedure satisfying the requirements set forth in section 12 of this chapter.
(11) Develop a utilization review plan and file a summary of the plan with the department.
As added by P.L.128-1992, SEC.1.