§ 27-8-16-4 — "Medical claims review" defined

(a) As used in this chapter, "medical claims
review" means the determination of the reimbursement to be provided
under the terms of an insurance policy, a health maintenance
organization contract, or another benefit program providing payment,
reimbursement, or indemnification for health care costs based on the
appropriateness of health care services or the amount charged for a
health care service delivered to an enrollee.
(b) The term does not include the prospective, concurrent, or
retrospective utilization review of health care services.
(c) The term does not include the identification of alternative,
optional medical care that:
(1) requires the approval of the enrollee or covered individual;
and
(2) does not affect coverage or benefits if rejected by the enrollee
or covered individual.

Legislative History

As added by P.L.128-1992, SEC.2. Amended by P.L.135-1994, SEC.1.