§ 27-1-37.5-17 — Peer to peer review; request

Indiana § 27-1-37.5-17

• Jurisdiction: Indiana
• Title 27: INSURANCE
• Art. 1: DEPARTMENT OF INSURANCE
• Ch. 37.5: Health Care Service Prior Authorization

Text

(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 health care service that may be required.
(b) If a utilization review entity makes an adverse determination on
a prior authorization request by a covered individual's health care
provider, the utilization review entity 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 utilization review entity'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 forty-eight (48) hours (excluding weekends
and state and federal legal holidays) after the utilization review
entity receives the request by the covered individual's health care
provider for a peer to peer review if the utilization review entity
has received the necessary information for the peer to peer
review; and
(2) the utilization review entity 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.

Legislative History

As added by P.L.190-2023, SEC.18. Amended by P.L.144-2025, SEC.27.