§ 27-8-16-7 — Minimum claim review agent requirements

A claim review agent must satisfy the
following minimum requirements:
(1) Provide toll free telephone access at least forty (40) hours each
week during normal business hours.
(2) Maintain a telephone call recording system capable of
accepting or recording incoming telephone calls or providing
instructions during hours other than normal business hours.
(3) Respond to each telephone call left on the recording system
maintained under subdivision (2) within two (2) business days
after receiving the call.
(4) Protect the confidentiality of the medical records disclosed to
the claim review agent.
(5) Include in every notification of a medical review
determination based on the appropriateness of health care services
delivered to an enrollee the principal reason for the determination.
(6) Ensure that every medical claims review determination based
on the appropriateness of health care services delivered to an
enrollee is:
(A) made by a provider; or
(B) determined in accordance with standards or guidelines
approved by a provider;
who holds a license in the same discipline as the provider who
rendered the service.
(7) Include in every notification of a medical review
determination based on the appropriateness of the amount
charged for a health care service delivered to an enrollee the
following:
(A) An explanation of the factual basis for the determination.
(B) If the determination is based on any information from a
claims data base, the name and address of the person or entity
compiling the data base.
(C) If the determination is based on any information from a
claims data base, a statement whether any of the information
was obtained from a data base regarding amounts charged for
health services performed outside Indiana.
(D) Any percentile limiter applied to determine the
appropriateness of an amount charged for a health service
provided to an enrollee.
(8) Ensure that every provider referred to in subdivision (6) who
makes medical claims review determinations or approves
standards or guidelines for medical claims review determinations
for the claim review agent has a current license issued by a state
licensing agency in the United States.
(9) Develop a medical claims review plan and file a summary of
the plan with the department.

Legislative History

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