Indiana Code 27-8-16-4. “Medical claims review” defined
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Sec. 4. (a) As used in this chapter, “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.
(c) The term does not include the identification of alternative, optional medical care that:
(b) The term does not include the prospective, concurrent, or retrospective utilization review of health care services.
Terms Used In Indiana Code 27-8-16-4
- 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
(1) requires the approval of the enrollee or covered individual; and
(2) does not affect coverage or benefits if rejected by the enrollee or covered individual.
As added by P.L.128-1992, SEC.2. Amended by P.L.135-1994, SEC.1.