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 thedepartment 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 individualwho has contracted for or who participates in coverage under aninsurance policy issued under insurance classes 1(b) and 2(a) ofIC 27-1-5-1, health maintenance organization contract, or otherbenefit program providing payment, reimbursement, orindemnification 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 thephysician or other licensed practitioner identified to a utilizationreview 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 asystem for prospective, concurrent, or retrospective review of themedical necessity and appropriateness of health care servicesprovided 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, orbenefits 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 forhospitals, home health agencies, health maintenanceorganizations, preferred provider organizations or othermanaged care entities, clinics, private offices, or any otherhealth facility, so long as the review does not result in theapproval or denial of an enrollee's coverage for hospital ormedical services.
(b) However, an agent described in subsection (a)(2) whoperforms utilization review for a person other than the federal orstate government is a utilization review agent who is subject to therequirements 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 reviewdetermination" means the rendering of a decision based on utilizationreview that denies or affirms either of the following:
(1) The necessity or appropriateness of the allocation ofresources.
(2) The provision or proposed provision of health care servicesto 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 thecovered 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 utilizationreview in Indiana unless the utilization review agent holds acertificate of registration issued by the department under this chapter.
(b) To obtain a certificate of registration under this chapter, autilization review agent must submit to the department an applicationcontaining 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 thedepartment may contact concerning the information in theapplication.
(3) Documentation necessary for the department to determinethat the utilization review agent is capable of satisfying theminimum 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 establishedunder subsection (d).
The commissioner shall deposit an application fee collected underthis subsection into the department of insurance fund established byIC 27-1-3-28.
(d) The department shall set the amount of the application feerequired by subsection (c) and section 10(a) of this chapter in therules adopted under section 20 of this chapter. The amount may notbe more than is reasonably necessary to generate revenue sufficientto offset the costs incurred by the department in carrying out itsresponsibilities under this chapter.
(e) The department shall issue a certificate of registration to autilization 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 ininformation
Sec. 10. (a) To remain in effect, a certificate of registration issuedunder this chapter must be renewed on June 30 of each year. Toobtain the renewal of a certificate of registration, a utilization reviewagent must submit an application to the commissioner. Theapplication must be accompanied by a registration fee in the amountset under section 9(d) of this chapter. The commissioner shall deposita registration fee collected under this subsection into the departmentof insurance fund established by IC 27-1-3-28.
(b) A certificate of registration issued under this chapter may notbe transferred unless the department determines that the entity towhom the certificate is to be transferred has satisfied therequirements of this chapter.
(c) If there is a material change in any of the information set forthin an application submitted under this chapter, the utilization reviewagent that submitted the application shall notify the department of thechange 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) hourseach week during normal business hours.
(2) Maintain a telephone call recording system capable ofaccepting or recording incoming telephone calls or providinginstructions during hours other than normal business hours.
(3) Respond to each telephone call left on the recording systemmaintained under subdivision (2) within two (2) business daysafter receiving the call.
(4) Protect the confidentiality of the medical records of coveredindividuals.
(5) Within two (2) business days after receiving a request for autilization review determination that includes all informationnecessary to complete the utilization review determination,notify the enrollee or the provider of record of the utilizationreview determination by mail or another means ofcommunication.
(6) Include in the notification of a utilization reviewdetermination not to certify an admission, a service, or aprocedure:
(A) if the determination not to certify is based on medicalnecessity or appropriateness of the admission, service, orprocedure, 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 thenecessity or appropriateness of an admission, a service, or aprocedure is:
(A) reviewed by a physician; or
(B) determined in accordance with standards or guidelinesapproved by a physician.
(8) Ensure that every physician making a utilization reviewdetermination for the utilization review agent has a currentlicense issued by a state licensing agency in the United States.
(9) Provide a period of at least forty-eight (48) hours followingan 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 certificationor continuing treatment for the condition involved in theadmission, service, or procedure.
(10) Provide an appeals procedure satisfying the requirementsset forth in section 12 of this chapter.
(11) Develop a utilization review plan and file a summary of theplan 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 anenrollee, 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 anenrollee or a provider of record may appeal the utilizationreview determination by the utilization review agent; and
(2) in the case of an enrollee covered under an accident andsickness policy or a health maintenance organization contractdescribed in subsection (d), notice that the enrollee has the rightto appeal the utilization review determination under IC 27-8-28or IC 27-13-10 and the toll free telephone number that theenrollee may call to request a review of the determination orobtain further information about the right to appeal.
(b) The appeals procedure provided by a utilization review agentmust meet the following requirements:
(1) On appeal, the determination not to certify an admission, aservice, or a procedure as necessary or appropriate must bemade by a health care provider licensed in the same disciplineas the provider of record.
(2) The determination of the appeal of a utilization reviewdetermination not to certify an admission, service, or proceduremust be completed within thirty (30) days after:
(A) the appeal is filed; and
(B) all information necessary to complete the appeal isreceived.
(c) A utilization review agent shall provide an expedited appealsprocess for emergency or life threatening situations. Thedetermination of an expedited appeal under the process required bythis subsection shall be made by a physician and completed withinforty-eight (48) hours after:
(1) the appeal is initiated; and
(2) all information necessary to complete the appeal is receivedby the utilization review agent.
(d) If an enrollee is covered under an accident and sicknessinsurance policy (as defined in IC 27-8-28-1) or a contract issued bya health maintenance organization (as defined in IC 27-13-1-19), theenrollee's exclusive right to appeal a utilization review determinationis provided under IC 27-8-28 or IC 27-13-10, respectively.
(e) A utilization review agent shall make available upon requesta written description of the appeals procedure that an enrollee orprovider of record may use to obtain a review of a utilization reviewdetermination 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 autilization review agent is capable of satisfying the requirement ofsection 11(7) of this chapter, as required by section 9(b)(3) of thischapter, the utilization review agent may provide a signed statementof a physician employed by or under contract to the utilization
review agent verifying that determinations made by the utilizationreview agent as to the necessity or appropriateness of admissions,services, and procedures are reviewed by a physician or determinedin 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; newcertificate of registration; order to cease activities
Sec. 14. (a) The department may, according to the rules adoptedunder section 20 of this chapter, determine that a utilization reviewagent satisfies the requirements set forth in section 11 of this chapterif the utilization review agent:
(1) has, at the time of issuance of the agent's certificate ofregistration, received; and
(2) maintains;
the approval or accreditation of a utilization review accreditationorganization that has been approved by the department for thepurposes of this section. The department may not make adetermination under this subsection before July 1, 1993.
(b) If a utilization review agent:
(1) is determined to satisfy the requirements of section 11 ofthis chapter by obtaining accreditation from a utilization reviewaccreditation organization; and
(2) subsequently loses the accreditation from the accreditingorganization;
the utilization review agent must, within sixty (60) days after losingits accreditation, obtain a new certificate of registration under thischapter to continue to conduct utilization review in Indiana. Duringthe sixty (60) day period, the utilization review agent may continueto conduct utilization review subject to all other requirements of thischapter, 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 utilizationreview agent cannot satisfy the requirements for issuance of acertificate of registration under this chapter, the department shallorder the utilization review agent to immediately cease all utilizationreview 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 benefitprogram
Sec. 15. (a) The following requirements apply to an enrollee'srequest for certification by a utilization review agent of anadmission, a service, or a procedure:
(1) In the absence of contractual terms to the contrary, theenrollee is responsible for notifying the utilization review agentof 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 recordor a responsible patient representative, including a familymember, to assist the enrollee in fulfilling the enrollee'sresponsibility under subdivision (1).
(3) The provider of record shall, within a reasonable time,provide to the utilization review agent all relevant informationnecessary to certify the admission, service, or procedure. For anemergency admission or procedure, the information shall beprovided within two (2) business days after the emergencyadmission or procedure. For an elective admission, procedure,or treatment, the information shall be provided not later thantwo (2) business days before the admission or the provision ofthe procedure or treatment.
(b) The failure to provide the information required by this sectionmay result in the denial of certification in accordance with the termsof the enrollee's insurance policy, health maintenance organizationcontract, 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 aprovider of record or an enrollee who provides fraudulent ormisleading information is subject to appropriate administrative, civil,and criminal penalties, including the penalty for deception underIC 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 reviewagent has violated this chapter, the department shall notify theutilization review agent of the alleged violation.
(b) The utilization review agent shall respond to a notice givenunder subsection (a) within thirty (30) days after receiving the notice.
(c) If the department:
(1) believes that a utilization review agent has violated thischapter; and
(2) is not satisfied, based on the response given by theutilization review agent under subsection (b), that the violationhas been corrected;
the department shall order the utilization review agent underIC 4-21.5-3-6 to cease all utilization review activities in Indiana.
(d) If the department determines that a utilization review agent hasviolated this chapter, the department:
(1) shall order the utilization review agent to cease and desistfrom engaging in the violation; and
(2) may do either or both of the following: (A) Order the utilization review agent to pay a civil penaltyof not more than five thousand dollars ($5,000) if theutilization review agent has committed violations with afrequency that indicates a general business practice.
(B) Suspend or revoke the certificate of registration of theutilization review agent.
(e) Any order issued or ruling made by the department under thissection 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 reviewagent to disclose information that is proprietary.
(b) Any:
(1) information concerning standards, criteria, or medicalprotocols used by a utilization review agent in conductingutilization review; or
(2) other proprietary information concerning utilization reviewconducted by a utilization review agent;
that is disclosed to the department of insurance under this chapter isconfidential for the purposes of IC 5-14-3-4(a)(1) and may not bedisclosed 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 theperformance 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 forpayment.
As added by P.L.128-1992, SEC.1.
IC 27-8-17-20
Rules
Sec. 20. The department shall adopt rules under IC 4-22-2necessary to carry out this chapter.
As added by P.L.128-1992, SEC.1.