Indiana § 27-1-37.5-20 Use of clinical peer when an adverse determination is made or when
reviewing or deciding an appeal

Indiana Statutes

§ 27-1-37.5-20 — Use of clinical peer when an adverse determination is made or when reviewing or deciding an appeal

Indiana § 27-1-37.5-20

Title 27INSURANCE

Art. 1DEPARTMENT OF INSURANCE

Ch. 37.5Health Care Service Prior Authorization

This text of Indiana § 27-1-37.5-20 (Use of clinical peer when an adverse determination is made or when reviewing or deciding an appeal) is published on Counsel Stack Legal Research, covering Indiana primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook

Ind. Code § 27-1-37.5-20 (2026).

Text

(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.

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(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.