Indiana Code 27-8-17-15. Certification of admission, service, or procedure; enrollee request; notice and information; assistance; denial under terms of benefit program
(1) In the absence of contractual terms to the contrary, the enrollee is responsible for notifying the utilization review agent of the admission, service, or procedure in a timely manner and for obtaining certification of health care services.
Terms Used In Indiana Code 27-8-17-15
- 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 issued under insurance classes 1(b) and 2(a) of IC 27-1-5-1, health maintenance organization contract, or other benefit program providing payment, reimbursement, or indemnification for the costs of health care for:
Indiana Code 27-8-17-3
- health maintenance organization: has the meaning set forth in IC 27-13-1-19. See Indiana Code 27-8-17-4
- provider of record: means the physician or other licensed practitioner identified to a utilization review agent as having primary responsibility for the care, treatment, and services rendered to a covered individual. See Indiana Code 27-8-17-5
- utilization review: means a system for prospective, concurrent, or retrospective review of the medical necessity and appropriateness of health care services provided or proposed to be provided to a covered individual. See Indiana Code 27-8-17-6
- utilization review agent: means any entity performing utilization review, except the following:
Indiana Code 27-8-17-7
(3) The provider of record shall, within a reasonable time, provide to the utilization review agent all relevant information necessary to certify the admission, service, or procedure. For an emergency admission or procedure, the information shall be provided within two (2) business days after the emergency admission or procedure. For an elective admission, procedure, or treatment, the information shall be provided not later than two (2) business days before the admission or the provision of the procedure or treatment.
(b) The failure to provide the information required by this section may result in the denial of certification in accordance with the terms of the enrollee’s insurance policy, health maintenance organization contract, or other benefit program.
As added by P.L.128-1992, SEC.1.