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Indiana Code Title 27. Insurance § 27-1-37.5-23

Current as of January 02, 2024 | Updated by Findlaw Staff

Sec. 23. (a) The time frames set forth in this section do not include weekends and state and federal legal holidays.

(b) A utilization review entity shall respond to a request for prior authorization as follows:

(1) If the request for prior authorization is for an urgent health care service, the utilization review entity shall respond with an authorization or adverse determination not later than twenty-four (24) hours after receiving the request.

(2) If the request for prior authorization is:

(A) for a health care service other than the health care services described in subdivision (1);  or

(B) for a prescription drug;

the utilization review entity shall respond with an authorization or adverse determination not later than forty-eight (48) hours after receiving the request.

(c) If a utilization review entity issues an adverse determination in a response under subsection (b), the response must include the following information:

(1) Specific reasons for the adverse determination.

(2) Suggested alternatives to the requested health care service.

(d) A health care provider shall respond not later than forty-eight (48) hours after receiving an adverse determination under subsection (b) if the health care provider:

(1) needs to correct a typographical, clerical, or spelling error;  or

(2) accepts an alternative suggested by the utilization review entity.

(e) Not later than forty-eight (48) hours after receiving a health care provider's response under subsection (d), the utilization review entity shall:

(1) render a prior authorization or adverse determination based on the information provided in the health care provider's response;  and

(2) notify the health care provider of the authorization or adverse determination.

(f) A health care provider may appeal an adverse determination received under subsection (b) or (e).  The health care provider shall notify the utilization review entity of an appeal not later than forty-eight (48) hours after receiving notice of the adverse determination.

(g) A utilization review entity shall respond to an appeal under subsection (f) not later than forty-eight (48) hours after receiving notice of the appeal.

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Cite this article: FindLaw.com - Indiana Code Title 27. Insurance § 27-1-37.5-23 - last updated January 02, 2024 | https://codes.findlaw.com/in/title-27-insurance/in-code-sect-27-1-37-5-23/

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