Indiana Code 27-8-16-1.5. “Claim review consultant” defined
(1) makes a recommendation or provides consultation to:
Terms Used In Indiana Code 27-8-16-1.5
- claim review agent: means any entity performing medical claims review on behalf of an insurance company, a health maintenance organization, or another benefit program providing payment, reimbursement, or indemnification for health care costs to an enrollee. See Indiana Code 27-8-16-1
- claim review consultant: means a person who:
Indiana Code 27-8-16-1.5
- Contract: A legal written agreement that becomes binding when signed.
- enrollee: means an individual who has contracted for or who participates in coverage under an insurance policy, a health maintenance organization contract, or another benefit program providing payment, reimbursement, or indemnification for the costs of health care for:
Indiana Code 27-8-16-3
- Indemnification: In general, a collateral contract or assurance under which one person agrees to secure another person against either anticipated financial losses or potential adverse legal consequences. Source: FDIC
- medical claims review: means the determination of the reimbursement to be provided under the terms of an insurance policy, a health maintenance organization contract, or another benefit program providing payment, reimbursement, or indemnification for health care costs based on the appropriateness of health care services or the amount charged for a health care service delivered to an enrollee. See Indiana Code 27-8-16-4
- person: means an individual, a corporation, a limited liability company, a partnership, or an unincorporated association. See Indiana Code 27-8-16-4.5
- Trial: A hearing that takes place when the defendant pleads "not guilty" and witnesses are required to come to court to give evidence.
- Year: means a calendar year, unless otherwise expressed. See Indiana Code 1-1-4-5
(B) an insurance company, a health maintenance organization, or another benefit program providing payment, reimbursement, or indemnification for health care costs to an enrollee;
concerning the appropriateness of a health care service or the amount charged for a health care service delivered to an enrollee in Indiana; and
(2) is not an employee of an entity referred to in subdivision (1)(A) or (1)(B).
(b) Making a recommendation or providing consultation concerning a health care service does not render a person a claim review consultant under this section if the recommendation or consultation concerns:
(1) coverage provided; or
(2) medical services rendered;
under IC 22.
(c) The term “claim review consultant” does not include the following:
(1) An insurance company authorized under IC 27 to do business in Indiana.
(2) An entity acting on behalf of the federal or state government. However, an agent described in this subdivision who performs medical claims review for a person other than the federal or state government is a claim review agent who is subject to the requirements of this chapter.
(3) A health maintenance organization or limited service health maintenance organization that holds a certificate of authority to operate under IC 27-13.
(4) An insurance administrator that is licensed under IC 27-1-25.
(5) An individual qualified and acting as an expert witness under the Indiana Rules of Trial Procedure.
(6) A person who engages in the prospective, concurrent, or retrospective utilization review of health care services.
(7) A person who engages in the identification of alternative, optional medical care that:
(A) requires the approval of the enrollee or covered individual; and
(B) does not affect coverage or benefits if rejected by the enrollee or covered individual.
(8) An individual who is a licensed health care provider who makes a recommendation or provides consultation concerning the appropriateness of health care service. However, this exception does not apply if the individual:
(A) makes any recommendations or provides consultation concerning the amount charged for a health care service delivered in Indiana;
(B) makes any recommendations or provides consultation concerning the appropriateness of hospital services provided by a hospital licensed under IC 12-25 or IC 16-21;
(C) is employed by or under contract with an entity that is required to be registered under this chapter; or
(D) has received more than five thousand dollars ($5,000) in compensation during the present calendar year for providing consultation services concerning the appropriateness of health care services delivered to enrollees in Indiana.
(9) A claim review agent under section 1 of this chapter.
As added by P.L.260-1995, SEC.2. Amended by P.L.160-2003, SEC.26.