Indiana Code 27-8-16-7. Minimum claim review agent requirements
(1) Provide toll free telephone access at least forty (40) hours each week during normal business hours.
Terms Used In Indiana Code 27-8-16-7
- 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
- department: refers to the department of insurance. See Indiana Code 27-8-16-2
- 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
- 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
- United States: includes the District of Columbia and the commonwealths, possessions, states in free association with the United States, and the territories. See Indiana Code 1-1-4-5
(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 disclosed to the claim review agent.
(5) Include in every notification of a medical review determination based on the appropriateness of health care services delivered to an enrollee the principal reason for the determination.
(6) Ensure that every medical claims review determination based on the appropriateness of health care services delivered to an enrollee is:
(A) made by a provider; or
(B) determined in accordance with standards or guidelines approved by a provider;
who holds a license in the same discipline as the provider who rendered the service.
(7) Include in every notification of a medical review determination based on the appropriateness of the amount charged for a health care service delivered to an enrollee the following:
(A) An explanation of the factual basis for the determination.
(B) If the determination is based on any information from a claims data base, the name and address of the person or entity compiling the data base.
(C) If the determination is based on any information from a claims data base, a statement whether any of the information was obtained from a data base regarding amounts charged for health services performed outside Indiana.
(D) Any percentile limiter applied to determine the appropriateness of an amount charged for a health service provided to an enrollee.
(8) Ensure that every provider referred to in subdivision (6) who makes medical claims review determinations or approves standards or guidelines for medical claims review determinations for the claim review agent has a current license issued by a state licensing agency in the United States.
(9) Develop a medical claims review plan and file a summary of the plan with the department.
As added by P.L.128-1992, SEC.2. Amended by P.L.135-1994, SEC.2.