CHAPTER 17. HEALTH CARE UTILIZATION REVIEW
IC 27-8-17
Chapter 17. Health Care Utilization Review
IC 27-8-17-1
"Covered individual" defined
Sec. 1. As used in this chapter, "covered individual" means:
(1) an enrollee; or
(2) an eligible dependent of an enrollee.
As added by P.L.128-1992, SEC.1.
IC 27-8-17-2
"Department" defined
Sec. 2. As used in this chapter, "department" refers to the
department of insurance.
As added by P.L.128-1992, SEC.1.
IC 27-8-17-3
"Enrollee" defined
Sec. 3. As used in this chapter, "enrollee" means an individual
who has contracted for or who participates in coverage under an
insurance policy issued under insurance classes 1(b) and 2(a) of
IC 27-1-5-1, health maintenance organization contract, or other
benefit program providing payment, reimbursement, or
indemnification for the costs of health care for:
(1) the individual;
(2) eligible dependents of the individual; or
(3) both the individual and the individual's eligible dependents.
As added by P.L.128-1992, SEC.1.
IC 27-8-17-4
"Health maintenance organization" defined
Sec. 4. As used in this chapter, "health maintenance organization"
has the meaning set forth in IC 27-13-1-19.
As added by P.L.128-1992, SEC.1. Amended by P.L.26-1994,
SEC.18.
IC 27-8-17-5
"Provider of record" defined
Sec. 5. As used in this chapter, "provider of record" means the
physician or other licensed practitioner identified to a utilization
review agent as having primary responsibility for the care, treatment,
and services rendered to a covered individual.
As added by P.L.128-1992, SEC.1.
IC 27-8-17-6
"Utilization review" defined
Sec. 6. (a) As used in this chapter, "utilization review" means a
system for prospective, concurrent, or retrospective review of the
medical necessity and appropriateness of health care services
provided or proposed to be provided to a covered individual.
(b) The term does not include the following:
(1) Elective requests for clarification of coverage, eligibility, or
benefits verification.
(2) Medical claims review (as defined in IC 27-8-16-4).
As added by P.L.128-1992, SEC.1.
IC 27-8-17-7
"Utilization review agent" defined
Sec. 7. (a) As used in this chapter, "utilization review agent"
means any entity performing utilization review, except the following:
(1) An agency of the state or federal government.
(2) An agent acting on behalf of the federal or state government.
(3) Entities conducting general in-house utilization review for
hospitals, home health agencies, health maintenance
organizations, preferred provider organizations or other
managed care entities, clinics, private offices, or any other
health facility, so long as the review does not result in the
approval or denial of an enrollee's coverage for hospital or
medical services.
(b) However, an agent described in subsection (a)(2) who
performs utilization review for a person other than the federal or
state government is a utilization review agent who is subject to the
requirements of this chapter.
As added by P.L.128-1992, SEC.1.
IC 27-8-17-8
"Utilization review determination" defined
Sec. 8. (a) As used in this chapter, "utilization review
determination" means the rendering of a decision based on utilization
review that denies or affirms either of the following:
(1) The necessity or appropriateness of the allocation of
resources.
(2) The provision or proposed provision of health care services
to a covered individual.
(b) The term does not include the identification of alternative,
optional medical care that:
(1) requires the approval of the covered individual; and
(2) does not affect coverage or benefits if rejected by the
covered individual.
As added by P.L.128-1992, SEC.1.
IC 27-8-17-9
Certificate of registration; issuance to agent
Sec. 9. (a) A utilization review agent may not conduct utilization
review in Indiana unless the utilization review agent holds a
certificate of registration issued by the department under this chapter.
(b) To obtain a certificate of registration under this chapter, a
utilization review agent must submit to the department an application
containing the following:
(1) The name, address, telephone number, and normal business
hours of the utilization review agent.
(2) The name and telephone number of a person that the
department may contact concerning the information in the
application.
(3) Documentation necessary for the department to determine
that the utilization review agent is capable of satisfying the
minimum requirements set forth in section 11 of this chapter.
(c) An application submitted under this section must be:
(1) signed and verified by the applicant; and
(2) accompanied by an application fee in the amount established
under subsection (d).
The commissioner shall deposit an application fee collected under
this subsection into the department of insurance fund established by
IC 27-1-3-28.
(d) The department shall set the amount of the application fee
required by subsection (c) and section 10(a) of this chapter in the
rules adopted under section 20 of this chapter. The amount may not
be more than is reasonably necessary to generate revenue sufficient
to offset the costs incurred by the department in carrying out its
responsibilities under this chapter.
(e) The department shall issue a certificate of registration to a
utilization review agent that satisfies the requirements of this section.
As added by P.L.128-1992, SEC.1. Amended by P.L.173-2007,
SEC.39; P.L.234-2007, SEC.196.
IC 27-8-17-10
Certificate of registration; renewal; transfer; notice of change in
information
Sec. 10. (a) To remain in effect, a certificate of registration issued
under this chapter must be renewed on June 30 of each year. To
obtain the renewal of a certificate of registration, a utilization review
agent must submit an application to the commissioner. The
application must be accompanied by a registration fee in the amount
set under section 9(d) of this chapter. The commissioner shall deposit
a registration fee collected under this subsection into the department
of insurance fund established by IC 27-1-3-28.
(b) A certificate of registration issued under this chapter may not
be transferred unless the department determines that the entity to
whom the certificate is to be transferred has satisfied the
requirements of this chapter.
(c) If there is a material change in any of the information set forth
in an application submitted under this chapter, the utilization review
agent that submitted the application shall notify the department of the
change in writing within thirty (30) days after the change.
As added by P.L.128-1992, SEC.1. Amended by P.L.173-2007,
SEC.40; P.L.234-2007, SEC.197.
IC 27-8-17-11
Minimum utilization review agent requirements
Sec. 11. A utilization 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 of covered
individuals.
(5) Within two (2) business days after receiving a request for a
utilization review determination that includes all information
necessary to complete the utilization review determination,
notify the enrollee or the provider of record of the utilization
review determination by mail or another means of
communication.
(6) Include in the notification of a utilization review
determination not to certify an admission, a service, or a
procedure:
(A) if the determination not to certify is based on medical
necessity or appropriateness of the admission, service, or
procedure, the principal reason for that determination; and
(B) the procedures to initiate an appeal of the determination.
(7) Ensure that every utilization review determination as to the
necessity or appropriateness of an admission, a service, or a
procedure is:
(A) reviewed by a physician; or
(B) determined in accordance with standards or guidelines
approved by a physician.
(8) Ensure that every physician making a utilization review
determination for the utilization review agent has a current
license issued by a state licensing agency in the United States.
(9) Provide a period of at least forty-eight (48) hours following
an emergency admission, service, or procedure during which:
(A) an enrollee; or
(B) the representative of an enrollee;
may notify the utilization review agent and request certification
or continuing treatment for the condition involved in the
admission, service, or procedure.
(10) Provide an appeals procedure satisfying the requirements
set forth in section 12 of this chapter.
(11) Develop a utilization review plan and file a summary of the
plan with the department.
As added by P.L.128-1992, SEC.1.
IC 27-8-17-12
Appeals procedure
Sec. 12. (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.
As added by P.L.128-1992, SEC.1. Amended by P.L.66-2001, SEC.1;
P.L.203-2001, SEC.12; P.L.1-2002, SEC.112.
IC 27-8-17-13
Physician's statement; documentation of review agent capability
Sec. 13. To provide documentation demonstrating that a
utilization review agent is capable of satisfying the requirement of
section 11(7) of this chapter, as required by section 9(b)(3) of this
chapter, the utilization review agent may provide a signed statement
of a physician employed by or under contract to the utilization
review agent verifying that determinations made by the utilization
review agent as to the necessity or appropriateness of admissions,
services, and procedures are reviewed by a physician or determined
in accordance with standards or guidelines approved by a physician.
As added by P.L.128-1992, SEC.1.
IC 27-8-17-14
Accreditation and approval of review agent; determination; new
certificate of registration; order to cease activities
Sec. 14. (a) The department may, according to the rules adopted
under section 20 of this chapter, determine that a utilization review
agent satisfies the requirements set forth in section 11 of this chapter
if the utilization review agent:
(1) has, at the time of issuance of the agent's certificate of
registration, received; and
(2) maintains;
the approval or accreditation of a utilization review accreditation
organization that has been approved by the department for the
purposes of this section. The department may not make a
determination under this subsection before July 1, 1993.
(b) If a utilization review agent:
(1) is determined to satisfy the requirements of section 11 of
this chapter by obtaining accreditation from a utilization review
accreditation organization; and
(2) subsequently loses the accreditation from the accrediting
organization;
the utilization review agent must, within sixty (60) days after losing
its accreditation, obtain a new certificate of registration under this
chapter to continue to conduct utilization review in Indiana. During
the sixty (60) day period, the utilization review agent may continue
to conduct utilization review subject to all other requirements of this
chapter, unless ordered to cease under subsection (c).
(c) If the department determines, before the expiration of the sixty
(60) day period referred to in subsection (b), that the utilization
review agent cannot satisfy the requirements for issuance of a
certificate of registration under this chapter, the department shall
order the utilization review agent to immediately cease all utilization
review activities in Indiana.
As added by P.L.128-1992, SEC.1.
IC 27-8-17-15
Certification of admission, service, or procedure; enrollee request;
notice and information; assistance; denial under terms of benefit
program
Sec. 15. (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.
As added by P.L.128-1992, SEC.1.
IC 27-8-17-16
Fraudulent or misleading information; penalties
Sec. 16. A provider of record, an enrollee, or the agent of a
provider of record or an enrollee who provides fraudulent or
misleading information is subject to appropriate administrative, civil,
and criminal penalties, including the penalty for deception under
IC 35-43-5-3.
As added by P.L.128-1992, SEC.1.
IC 27-8-17-17
Violations; notice to agent; cease and desist orders; penalties;
revocation or suspension of registration; review
Sec. 17. (a) If the department believes that a utilization review
agent has violated this chapter, the department shall notify the
utilization review agent of the alleged violation.
(b) The utilization review agent shall respond to a notice given
under subsection (a) within thirty (30) days after receiving the notice.
(c) If the department:
(1) believes that a utilization review agent has violated this
chapter; and
(2) is not satisfied, based on the response given by the
utilization review agent under subsection (b), that the violation
has been corrected;
the department shall order the utilization review agent under
IC 4-21.5-3-6 to cease all utilization review activities in Indiana.
(d) If the department determines that a utilization review agent has
violated this chapter, the department:
(1) shall order the utilization review agent to cease and desist
from engaging in the violation; and
(2) may do either or both of the following:
(A) Order the utilization review agent to pay a civil penalty
of not more than five thousand dollars ($5,000) if the
utilization review agent has committed violations with a
frequency that indicates a general business practice.
(B) Suspend or revoke the certificate of registration of the
utilization review agent.
(e) Any order issued or ruling made by the department under this
section is subject to review under IC 4-21.5.
As added by P.L.128-1992, SEC.1.
IC 27-8-17-18
Confidential information
Sec. 18. (a) This chapter does not require a utilization review
agent to disclose information that is proprietary.
(b) Any:
(1) information concerning standards, criteria, or medical
protocols used by a utilization review agent in conducting
utilization review; or
(2) other proprietary information concerning utilization review
conducted by a utilization review agent;
that is disclosed to the department of insurance under this chapter is
confidential for the purposes of IC 5-14-3-4(a)(1) and may not be
disclosed by the department.
As added by P.L.128-1992, SEC.1. Amended by P.L.1-1993,
SEC.207.
IC 27-8-17-19
Prohibited bases for compensation of agent
Sec. 19. The compensation of a utilization review agent for the
performance of utilization review may not be based on:
(1) the extent to which certifications are denied; or
(2) the amount by which subsequent claims are reduced for
payment.
As added by P.L.128-1992, SEC.1.
IC 27-8-17-20
Rules
Sec. 20. The department shall adopt rules under IC 4-22-2
necessary to carry out this chapter.
As added by P.L.128-1992, SEC.1.