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Current as of January 02, 2024 | Updated by Findlaw Staff
Sec. 20. (a) A utilization review entity must ensure that:
(1) all:
(A) adverse determinations based on medical necessity are made; and
(B) appeals are reviewed and decided;
by a clinical peer; and
(2) when making an adverse determination based on medical necessity or reviewing and deciding an appeal, the clinical peer is under the clinical direction of a medical director of the utilization review entity who is:
(A) responsible for the provision of health care services provided to covered individuals; and
(B) a physician licensed in Indiana under IC 25-22.5.
(b) An appeal may not be reviewed or decided by a clinical peer who:
(1) has a financial interest in the outcome of the appeal; or
(2) was involved in making the adverse determination that is the subject of the appeal.
Cite this article: FindLaw.com - Indiana Code Title 27. Insurance § 27-1-37.5-20 - last updated January 02, 2024 | https://codes.findlaw.com/in/title-27-insurance/in-code-sect-27-1-37-5-20/
FindLaw Codes may not reflect the most recent version of the law in your jurisdiction. Please verify the status of the code you are researching with the state legislature before relying on it for your legal needs.
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