Indiana Code 27-8-17-7. “Utilization review agent” defined
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Sec. 7. (a) As used in this chapter, “utilization review agent” means any entity performing utilization review, except the following:
(2) An agent acting on behalf of the federal or state government.
(1) An agency of the state or federal government.
Terms Used In Indiana Code 27-8-17-7
- 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
- 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
(3) Entities conducting general in-house utilization review for hospitals, home health agencies, health maintenance organizations, preferred provider organizations or other managed care entities, clinics, private offices, or any other health facility, so long as the review does not result in the approval or denial of an enrollee‘s coverage for hospital or medical services.
(b) However, an agent described in subsection (a)(2) who performs utilization review for a person other than the federal or state government is a utilization review agent who is subject to the requirements of this chapter.
As added by P.L.128-1992, SEC.1.