Indiana Code 27-8-16-9.5. Claim determinations based on data base information
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Sec. 9.5. (a) As used in this section, “data base” means a data base that provides information concerning health care services or amounts charged for health care services.
(c) If a claim review consultant makes a recommendation or provides consultation concerning the appropriateness of or the amount charged for services provided by a hospital licensed under IC 12-25 or IC 16-21 based in whole or in part on information obtained from a data base, the information must relate exclusively to services provided by a hospital licensed under IC 12-25 or IC 16-21.
(b) If a claim review agent bases a medical claims review determination concerning a health care service provided by a hospital licensed under IC 12-25 or IC 16-21 in whole or in part on information obtained from a data base, the information must relate exclusively to services provided by a hospital licensed under IC 12-25 or IC 16-21.
Terms Used In Indiana Code 27-8-16-9.5
- 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
- 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
(d) This section does not apply to:
(1) medical claims review determinations made under subsection (b); or
(2) consultations or recommendations made under subsection (c);
regarding medical services provided under IC 22.
As added by P.L.260-1995, SEC.7.