§ 27-8-16-1.5 — "Claim review consultant" defined

Indiana § 27-8-16-1.5

• Jurisdiction: Indiana
• Title 27: INSURANCE
• Art. 8: LIFE, ACCIDENT, AND HEALTH
• Ch. 16: Medical Claims Review

Text

5. (a) As used in this chapter, "claim review
consultant" means a person who:
(1) makes a recommendation or provides consultation to:
(A) an entity engaged in performing medical claims review; or
(B) an insurance company, a health maintenance organization,
or another benefit program providing payment, reimbursement,
or indemnification for health care costs to an enrollee;
concerning the appropriateness of a health care service or the
amount charged for a health care service delivered to an enrollee
in Indiana; and
(2) is not an employee of an entity referred to in subdivision
(1)(A) or (1)(B).
(b) Making a recommendation or providing consultation concerning
a health care service does not render a person a claim review consultant
under this section if the recommendation or consultation concerns:
(1) coverage provided; or
(2) medical services rendered;
under IC 22.
(c) The term "claim review consultant" does not include the
following:
(1) An insurance company authorized under IC 27 to do business
in Indiana.
(2) An entity acting on behalf of the federal or state government.
However, an agent described in this subdivision who performs
medical claims review for a person other than the federal or state
government is a claim review agent who is subject to the
requirements of this chapter.
(3) A health maintenance organization or limited service health
maintenance organization that holds a certificate of authority to
operate under IC 27-13.
(4) An insurance administrator that is licensed under IC 27-1-25.
(5) An individual qualified and acting as an expert witness under
the Indiana Rules of Trial Procedure.
(6) A person who engages in the prospective, concurrent, or
retrospective utilization review of health care services.
(7) A person who engages in the identification of alternative,
optional medical care that:
(A) requires the approval of the enrollee or covered individual;
and
(B) does not affect coverage or benefits if rejected by the
enrollee or covered individual.
(8) An individual who is a licensed health care provider who
makes a recommendation or provides consultation concerning the
appropriateness of health care service. However, this exception
does not apply if the individual:
(A) makes any recommendations or provides consultation
concerning the amount charged for a health care service
delivered in Indiana;
(B) makes any recommendations or provides consultation
concerning the appropriateness of hospital services provided by
a hospital licensed under IC 12-25 or IC 16-21;
(C) is employed by or under contract with an entity that is
required to be registered under this chapter; or
(D) has received more than five thousand dollars ($5,000) in
compensation during the present calendar year for providing
consultation services concerning the appropriateness of health
care services delivered to enrollees in Indiana.
(9) A claim review agent under section 1 of this chapter.

Legislative History

As added by P.L.260-1995, SEC.2. Amended by P.L.160-2003, SEC.26.