Indiana § 27-8-17-12 Appeals procedure

Indiana Statutes

§ 27-8-17-12 — Appeals procedure

Indiana·Title 27 INSURANCE·Art. 8 LIFE, ACCIDENT, AND HEALTH·Ch. 17 Health Care Utilization Review

(a)A utilization review agent shall make available to an enrollee, and to a provider of record upon request, at the time an adverse utilization review determination is made:

(1)a written description of the appeals procedure by which an enrollee or a provider of record may appeal the utilization review determination by the utilization review agent; and

(2)in the case of an enrollee covered under an accident and sickness policy or a health maintenance organization contract described in subsection (d), notice that the enrollee has the right to appeal the utilization review determination under IC 27-8-28 or IC 27-13-10 and the toll free telephone number that the enrollee may call to request a review of the determination or obtain further information about the right to appeal.

(b)The appeal

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(a) A utilization review agent shall make
available to an enrollee, and to a provider of record upon request, at the
time an adverse utilization review determination is made:
(1) a written description of the appeals procedure by which an
enrollee or a provider of record may appeal the utilization review
determination by the utilization review agent; and
(2) in the case of an enrollee covered under an accident and
sickness policy or a health maintenance organization contract
described in subsection (d), notice that the enrollee has the right
to appeal the utilization review determination under IC 27-8-28
or IC 27-13-10 and the toll free telephone number that the
enrollee may call to request a review of the determination or
obtain further information about the right to appeal.
(b) The appeals procedure provided by a utilization review agent
must meet the following requirements:
(1) On appeal, the determination not to certify an admission, a
service, or a procedure as necessary or appropriate must be made
by a health care provider licensed in the same discipline as the
provider of record.
(2) The determination of the appeal of a utilization review
determination not to certify an admission, service, or procedure
must be completed within thirty (30) days after:
(A) the appeal is filed; and
(B) all information necessary to complete the appeal is
received.
(c) A utilization review agent shall provide an expedited appeals
process for emergency or life threatening situations. The determination
of an expedited appeal under the process required by this subsection
shall be made by a physician and completed within forty-eight (48)
hours after:
(1) the appeal is initiated; and
(2) all information necessary to complete the appeal is received
by the utilization review agent.
(d) If an enrollee is covered under an accident and sickness
insurance policy (as defined in IC 27-8-28-1) or a contract issued by a
health maintenance organization (as defined in IC 27-13-1-19), the
enrollee's exclusive right to appeal a utilization review determination
is provided under IC 27-8-28 or IC 27-13-10, respectively.
(e) A utilization review agent shall make available upon request a
written description of the appeals procedure that an enrollee or
provider of record may use to obtain a review of a utilization review
determination by the utilization review agent.