§ 27-8-17-15 — Certification of admission, service, or procedure; enrollee request; notice and information; assistance; denial under terms of benefit program

(a) The following requirements apply to an
enrollee's request for certification by a utilization review agent of an
admission, a service, or a procedure:
(1) In the absence of contractual terms to the contrary, the
enrollee is responsible for notifying the utilization review agent
of the admission, service, or procedure in a timely manner and for
obtaining certification of health care services.
(2) A utilization review agent shall allow the provider of record
or a responsible patient representative, including a family
member, to assist the enrollee in fulfilling the enrollee's
responsibility under subdivision (1).
(3) The provider of record shall, within a reasonable time, provide
to the utilization review agent all relevant information necessary
to certify the admission, service, or procedure. For an emergency
admission or procedure, the information shall be provided within
two (2) business days after the emergency admission or
procedure. For an elective admission, procedure, or treatment, the
information shall be provided not later than two (2) business days
before the admission or the provision of the procedure or
treatment.
(b) The failure to provide the information required by this section
may result in the denial of certification in accordance with the terms of
the enrollee's insurance policy, health maintenance organization
contract, or other benefit program.

Legislative History

As added by P.L.128-1992, SEC.1.