IC 27-1-37.5-20 — Use of clinical peer when an adverse determination is made or when reviewing or deciding an appeal
Chapter 37.5. Health Care Service Prior Authorization
Bills amending this section
Section text
Sec. 20. (a) A utilization review entity must ensure that: (1) all: (A) adverse determinations based on medical necessity are made; and (B) appeals are reviewed and decided; by a clinical peer; and (2) when making an adverse determination based on medical necessity or reviewing and deciding an appeal, the clinical peer is under the clinical direction of a medical director of the utilization review entity who is: (A) responsible for the provision of health care services provided to covered individuals; and (B) a physician licensed in Indiana under IC 25-22.5. (b) An appeal may not be reviewed or decided by a clinical peer who: (1) has a financial interest in the outcome of the appeal; or (2) was involved in making the adverse determination that is the subject of the appeal.
As added by P.L.144-2025, SEC.29.
Source: official publisher (2026 edition)