reglab/statecodes huggingface dataset:
2023 Indiana Code › Title 27. Insurance › Article 8. Life, Accident, and Health › Chapter 15. Small Employer Group Health Insurance › 27-8-15-33. Mandatory Coverage by Employer Insurer to All Employer's Eligible Employees and Employees' Dependents; Employees Declining Coverage; Minimum Participation and Contribution Requirements

Sec. 33. (a) If a small employer insurer offers coverage under a health insurance plan to a small employer, the small employer insurer shall provide the employer coverage under the plan for:
(1) all eligible employees of the small employer; and
(2) the dependents of all eligible employees of the small employer.
(b) Except as provided in section 29 of this chapter with respect to late enrollees, a small employer insurer shall not limit the insurer's provision of coverage to:
(1) certain individuals in a small employer group; or
(2) a part of a small employer group.
(c) This section does not prohibit an eligible employee from declining coverage under this section.
(d) Nothing in this chapter prohibits a small employer insurer from including minimum participation and contribution requirements in its offer of coverage.
As added by P.L.93-1995, SEC.22.
2023 Indiana Code › Title 27. Insurance › Article 8. Life, Accident, and Health › Chapter 15. Small Employer Group Health Insurance › 27-8-15-34.1. All Products Required to Be Offered; All Employers Required to Be Accepted

Sec. 34.1. Except as provided in 29 U.S.C. 1191a and 42 U.S.C. 300gg, a small employer insurer must:
(1) offer to any small employer all products that are approved for sale in the small group market and that the insurer is actively marketing; and
(2) accept any employer that applies for any of those products.
As added by P.L.91-1998, SEC.20.
2023 Indiana Code › Title 27. Insurance › Article 8. Life, Accident, and Health › Chapter 16. Medical Claims Review › 27-8-16-0.5. Applicability of Chapter

Sec. 0.5. (a) This chapter applies to the following:
(1) A person who conducts medical claims review concerning health care services delivered to an enrollee in Indiana.
(2) A person who acts as a claim review consultant concerning the:
(A) appropriateness of; or
(B) amount charged for;
a health care service delivered to an enrollee in Indiana.
(b) This chapter does not apply to:
(1) the payment of benefits or compensation;
(2) the furnishing of medical, surgical, hospital, or nursing services; or
(3) the payment by an insurer or employer to the provider of health care services for services provided;
under IC 22.
As added by P.L.260-1995, SEC.1.
2023 Indiana Code › Title 27. Insurance › Article 8. Life, Accident, and Health › Chapter 16. Medical Claims Review › 27-8-16-1. "Claim Review Agent" Defined

Sec. 1. (a) As used in this chapter, "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.
(b) The term does not include the following:
(1) An insurance company authorized under IC 27-1-3 or IC 27-1-17 to do business in Indiana or the company's affiliated companies.
(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.
As added by P.L.128-1992, SEC.2. Amended by P.L.26-1994, SEC.17; P.L.160-2003, SEC.25.
2023 Indiana Code › Title 27. Insurance › Article 8. Life, Accident, and Health › Chapter 16. Medical Claims Review › 27-8-16-1.5. "Claim Review Consultant" Defined

Sec. 1.5. (a) As used in this chapter, "claim review consultant" means a person who:
(1) makes a recommendation or provides consultation to:
(A) an entity engaged in performing medical claims review; or
(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.
2023 Indiana Code › Title 27. Insurance › Article 8. Life, Accident, and Health › Chapter 16. Medical Claims Review › 27-8-16-3. "Enrollee" Defined

Sec. 3. As used in this chapter, "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:
(1) the individual;
(2) eligible dependents of the individual; or
(3) both the individual and the individual's eligible dependents.
As added by P.L.128-1992, SEC.2.
2023 Indiana Code › Title 27. Insurance › Article 8. Life, Accident, and Health › Chapter 16. Medical Claims Review › 27-8-16-4. "Medical Claims Review" Defined

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.
(b) The term does not include the prospective, concurrent, or retrospective utilization review of health care services.
(c) The term does not include the identification of alternative, optional medical care that:
(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.
2023 Indiana Code › Title 27. Insurance › Article 8. Life, Accident, and Health › Chapter 16. Medical Claims Review › 27-8-16-4.5. "Person" Defined

Sec. 4.5. As used in this chapter, "person" means an individual, a corporation, a limited liability company, a partnership, or an unincorporated association.
As added by P.L.260-1995, SEC.3.
2023 Indiana Code › Title 27. Insurance › Article 8. Life, Accident, and Health › Chapter 16. Medical Claims Review › 27-8-16-5. Certificate of Registration; Issuance to Agent

Sec. 5. (a) A claim review agent may not conduct medical claims review concerning health care services delivered to an enrollee in Indiana unless the claim review agent holds a certificate of registration issued by the department under this chapter.
(b) To obtain a certificate of registration under this chapter, a claim review agent must submit to the department an application containing the following:
(1) The name, address, telephone number, and normal business hours of the claim review agent.
(2) The name and telephone number of a person that the department may contact concerning the information in the application.
(3) Documentation necessary for the department to determine that the claim review agent is capable of satisfying the minimum requirements set forth in section 7 of this chapter.
(c) An application submitted under this section must be:
(1) signed and verified by the applicant; and
(2) accompanied by an application fee in the amount established under subsection (d).
The commissioner shall deposit an application fee collected under this subsection into the department of insurance fund established by IC 27-1-3-28.
(d) The department shall set the amount of the application fee required by subsection (c) and section 6(a) of this chapter in the rules adopted under section 14 of this chapter. The amount may not be more than is reasonably necessary to generate revenue sufficient to offset the costs incurred by the department in carrying out the department's responsibilities under this chapter.
(e) The department shall issue a certificate of registration to a claim review agent that satisfies the requirements of this section.
As added by P.L.128-1992, SEC.2. Amended by P.L.260-1995, SEC.4; P.L.173-2007, SEC.36; P.L.234-2007, SEC.193.
2023 Indiana Code › Title 27. Insurance › Article 8. Life, Accident, and Health › Chapter 16. Medical Claims Review › 27-8-16-5.2. Certificate of Registration; Application; Requirements; Application Fee

Sec. 5.2. (a) A person may not act as a claim review consultant concerning health care services delivered to an enrollee in Indiana unless the person holds a certificate of registration issued by the department under this chapter.
(b) To obtain a certificate of registration under this chapter, a person must submit to the department an application containing the following:
(1) The name, address, telephone number, and normal business hours of the person.
(2) The name and telephone number of a person that the department may contact concerning the information in the application.
(3) Documentation necessary for the department to determine that the person is capable of satisfying the minimum requirements set forth in this chapter.
(c) An application submitted under this section must be:
(1) signed and verified by the applicant; and
(2) accompanied by an application fee in the amount established under subsection (d).
The commissioner shall deposit an application fee collected under this subsection into the department of insurance fund established by IC 27-1-3-28.
(d) The department shall set the amount of the application fee required by subsection (c) and section 6(a) of this chapter in the rules adopted under section 14 of this chapter. The amount may not be more than is reasonably necessary to generate revenue sufficient to offset the costs incurred by the department in carrying out the department's responsibilities under this chapter.
(e) The department shall issue a certificate of registration to a claim review consultant that satisfies the requirements of this section.
As added by P.L.260-1995, SEC.5. Amended by P.L.173-2007, SEC.37; P.L.234-2007, SEC.194.
2023 Indiana Code › Title 27. Insurance › Article 8. Life, Accident, and Health › Chapter 16. Medical Claims Review › 27-8-16-6. Certificate of Registration; Renewal; Transfer; Notice of Change in Information

Sec. 6. (a) To remain in effect, a certificate of registration issued under this chapter must be renewed annually. To obtain the renewal of a certificate of registration, a claim review agent or a claim review consultant must submit an application to the commissioner. The application must be accompanied by a registration fee in the amount set under section 5(d) of this chapter. The commissioner shall deposit a registration fee collected under this subsection into the department of insurance fund established by IC 27-1-3-28.
(b) A certificate of registration issued under this chapter may not be transferred unless the department determines that the person to which the certificate of registration is to be transferred has satisfied the requirements of this chapter.
(c) If there is a material change in any of the information set forth in an application submitted under this chapter, the claim review agent or claim review consultant that submitted the application shall notify the department of the change in writing not more than thirty (30) days after the change.
As added by P.L.128-1992, SEC.2. Amended by P.L.260-1995, SEC.6; P.L.173-2007, SEC.38; P.L.234-2007, SEC.195; P.L.146-2015, SEC.35.
2023 Indiana Code › Title 27. Insurance › Article 8. Life, Accident, and Health › Chapter 16. Medical Claims Review › 27-8-16-7. Minimum Claim Review Agent Requirements

Sec. 7. A claim review agent must satisfy the following minimum requirements:
(1) Provide toll free telephone access at least forty (40) hours each week during normal business hours.
(2) Maintain a telephone call recording system capable of accepting or recording incoming telephone calls or providing instructions during hours other than normal business hours.
(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.
2023 Indiana Code › Title 27. Insurance › Article 8. Life, Accident, and Health › Chapter 16. Medical Claims Review › 27-8-16-8. Appeals Procedure; Written Description; Minimum Standards; Notice of Appeal Procedure on Limitation or Reduction of Benefits

Sec. 8. (a) An insurance company, a health maintenance organization, or another benefit program providing payment, reimbursement, or indemnification for health care costs that contracts with a claim review agent for medical claims review services shall maintain and make available upon request a written description of the appeals procedure by which an enrollee may seek a review of a determination by the claim review agent.
(b) The appeals procedure referred to in subsection (a) must meet the following requirements:
(1) On appeal, the determination must be made by a provider who holds a license in the same discipline as the provider who rendered the service.
(2) The adjudication of an appeal of a determination must be completed within thirty (30) days after:
(A) the appeal is filed; and
(B) all information necessary to complete the appeal is received.
(c) If a medical review determination results in a limitation or reduction of benefits, a notice of the appeals procedure shall be provided by the claim review agent to the provider who rendered the health care services.
As added by P.L.128-1992, SEC.2.
2023 Indiana Code › Title 27. Insurance › Article 8. Life, Accident, and Health › Chapter 16. Medical Claims Review › 27-8-16-9. Provider's Statement; Documentation of Review Agent Capability

Sec. 9. To provide documentation demonstrating that a claim review agent is capable of satisfying the requirement of section 7(6) of this chapter, the claim review agent must provide a signed statement of a provider employed by the claim review agent verifying that determinations are:
(1) made by; or
(2) determined in accordance with standards or guidelines approved by;
a provider licensed in the same discipline as the provider who rendered the service.
As added by P.L.128-1992, SEC.2.
2023 Indiana Code › Title 27. Insurance › Article 8. Life, Accident, and Health › Chapter 16. Medical Claims Review › 27-8-16-9.5. Claim Determinations Based on Data Base Information

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.
(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.
(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.
(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.
2023 Indiana Code › Title 27. Insurance › Article 8. Life, Accident, and Health › Chapter 16. Medical Claims Review › 27-8-16-10. Fraudulent or Misleading Information; Penalties

Sec. 10. A provider, an enrollee, or an agent of a provider or enrollee who provides fraudulent or misleading information to a claim review agent is subject to the appropriate administrative, civil, and criminal penalties.
As added by P.L.128-1992, SEC.2.
2023 Indiana Code › Title 27. Insurance › Article 8. Life, Accident, and Health › Chapter 16. Medical Claims Review › 27-8-16-11. Prohibited Bases for Compensation of Claim Review Agents and Consultants

Sec. 11. (a) The compensation of a claim review agent for the performance of medical claims review may not be based on the amount by which claims are reduced for payment.
(b) The compensation of a claim review consultant for making a recommendation or providing consultation concerning the appropriateness of or amount charged for a health care service delivered to an enrollee in Indiana may not be based on the amount by which a claim relating to the service is reduced for payment.
As added by P.L.128-1992, SEC.2. Amended by P.L.260-1995, SEC.8.
2023 Indiana Code › Title 27. Insurance › Article 8. Life, Accident, and Health › Chapter 16. Medical Claims Review › 27-8-16-12. Violations; Claims Review Agent; Notice; Cease and Desist Orders; Penalties; Revocation or Suspension of Registration; Review

Sec. 12. (a) If the department believes that a claim review agent or claim review consultant has violated this chapter, the department shall notify the claim review agent or claim review consultant of the alleged violation.
(b) The claim review agent or claim review consultant shall respond to a notice given under subsection (a) within thirty (30) days after receiving the notice.
(c) If the department:
(1) believes that a claim review agent or claim review consultant has violated this chapter; and
(2) is not satisfied, based on the response given by the claim review agent or claim review consultant under subsection (b), that the violation has been corrected;
the department shall order the claim review agent or claim review consultant under IC 4-21.5-3-6 to cease all claims review activities in Indiana.
(d) If the department determines that a claim review agent or claim review consultant has violated this chapter, the department:
(1) shall order the claim review agent or claim review consultant to cease and desist from engaging in the violation; and
(2) may do either or both of the following:
(A) Order the claim review agent or claim review consultant to pay a civil penalty of not more than five thousand dollars ($5,000) if the claim review agent or claim review consultant has committed violations with a frequency that indicates a general business practice.
(B) Suspend or revoke the certificate of registration of the claim review agent or claim review consultant.
(e) An order issued or a ruling made by the department under this section is subject to review under IC 4-21.5.
As added by P.L.128-1992, SEC.2. Amended by P.L.260-1995, SEC.9.
2023 Indiana Code › Title 27. Insurance › Article 8. Life, Accident, and Health › Chapter 16. Medical Claims Review › 27-8-16-13. Confidential Information

Sec. 13. (a) This chapter does not require a claim review agent or claim review consultant to disclose information that is proprietary.
(b) Any:
(1) information concerning standards, criteria, or medical protocols used by a claim review agent in conducting medical claims review; and
(2) other proprietary information concerning medical claims review conducted by a claim review agent;
that is disclosed to the department under this chapter is confidential for the purposes of IC 5-14-3-4(a)(1).
As added by P.L.128-1992, SEC.2. Amended by P.L.260-1995, SEC.10.
2023 Indiana Code › Title 27. Insurance › Article 8. Life, Accident, and Health › Chapter 17. Health Care Utilization Review › 27-8-17-1. "Covered Individual" Defined

Sec. 1. As used in this chapter, "covered individual" means:
(1) an enrollee; or
(2) an eligible dependent of an enrollee.
As added by P.L.128-1992, SEC.1.
2023 Indiana Code › Title 27. Insurance › Article 8. Life, Accident, and Health › Chapter 17. Health Care Utilization Review › 27-8-17-3. "Enrollee" Defined

Sec. 3. As used in this chapter, "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:
(1) the individual;
(2) eligible dependents of the individual; or
(3) both the individual and the individual's eligible dependents.
As added by P.L.128-1992, SEC.1.
2023 Indiana Code › Title 27. Insurance › Article 8. Life, Accident, and Health › Chapter 17. Health Care Utilization Review › 27-8-17-4. "Health Maintenance Organization" Defined

Sec. 4. As used in this chapter, "health maintenance organization" has the meaning set forth in IC 27-13-1-19.
As added by P.L.128-1992, SEC.1. Amended by P.L.26-1994, SEC.18.
2023 Indiana Code › Title 27. Insurance › Article 8. Life, Accident, and Health › Chapter 17. Health Care Utilization Review › 27-8-17-5. "Provider of Record" Defined

Sec. 5. As used in this chapter, "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.
As added by P.L.128-1992, SEC.1.
2023 Indiana Code › Title 27. Insurance › Article 8. Life, Accident, and Health › Chapter 17. Health Care Utilization Review › 27-8-17-6. "Utilization Review" Defined

Sec. 6. (a) As used in this chapter, "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.
(b) The term does not include the following:
(1) Elective requests for clarification of coverage, eligibility, or benefits verification.
(2) Medical claims review (as defined in IC 27-8-16-4).
As added by P.L.128-1992, SEC.1.
2023 Indiana Code › Title 27. Insurance › Article 8. Life, Accident, and Health › Chapter 17. Health Care Utilization Review › 27-8-17-7. "Utilization Review Agent" Defined

Sec. 7. (a) As used in this chapter, "utilization review agent" means any entity performing utilization review, except the following:
(1) An agency of the state or federal government.
(2) An agent acting on behalf of the federal or state government.
(3) Entities conducting general in-house utilization review for hospitals, home health agencies, health maintenance organizations, preferred provider organizations or other managed care entities, clinics, private offices, or any other health facility, so long as the review does not result in the approval or denial of an enrollee's coverage for hospital or medical services.
(b) However, an agent described in subsection (a)(2) who performs utilization review for a person other than the federal or state government is a utilization review agent who is subject to the requirements of this chapter.
As added by P.L.128-1992, SEC.1.
2023 Indiana Code › Title 27. Insurance › Article 8. Life, Accident, and Health › Chapter 17. Health Care Utilization Review › 27-8-17-8. "Utilization Review Determination" Defined

Sec. 8. (a) As used in this chapter, "utilization review determination" means the rendering of a decision based on utilization review that denies or affirms either of the following:
(1) The necessity or appropriateness of the allocation of resources.
(2) The provision or proposed provision of health care services to a covered individual.
(b) The term does not include the identification of alternative, optional medical care that:
(1) requires the approval of the covered individual; and
(2) does not affect coverage or benefits if rejected by the covered individual.
As added by P.L.128-1992, SEC.1.
2023 Indiana Code › Title 27. Insurance › Article 8. Life, Accident, and Health › Chapter 17. Health Care Utilization Review › 27-8-17-9. Certificate of Registration; Issuance to Agent

Sec. 9. (a) A utilization review agent may not conduct utilization review in Indiana unless the utilization review agent holds a certificate of registration issued by the department under this chapter.
(b) To obtain a certificate of registration under this chapter, a utilization review agent must submit to the department an application containing the following:
(1) The name, address, telephone number, and normal business hours of the utilization review agent.
(2) The name and telephone number of a person that the department may contact concerning the information in the application.
(3) Documentation necessary for the department to determine that the utilization review agent is capable of satisfying the minimum requirements set forth in section 11 of this chapter.
(c) An application submitted under this section must be:
(1) signed and verified by the applicant; and
(2) accompanied by an application fee in the amount established under subsection (d).
The commissioner shall deposit an application fee collected under this subsection into the department of insurance fund established by IC 27-1-3-28.
(d) The department shall set the amount of the application fee required by subsection (c) and section 10(a) of this chapter in the rules adopted under section 20 of this chapter. The amount may not be more than is reasonably necessary to generate revenue sufficient to offset the costs incurred by the department in carrying out its responsibilities under this chapter.
(e) The department shall issue a certificate of registration to a utilization review agent that satisfies the requirements of this section.
As added by P.L.128-1992, SEC.1. Amended by P.L.173-2007, SEC.39; P.L.234-2007, SEC.196.
2023 Indiana Code › Title 27. Insurance › Article 8. Life, Accident, and Health › Chapter 17. Health Care Utilization Review › 27-8-17-10. Certificate of Registration; Renewal; Transfer; Notice of Change in Information

Sec. 10. (a) To remain in effect, a certificate of registration issued under this chapter must be renewed annually. To obtain the renewal of a certificate of registration, a utilization review agent must submit an application to the commissioner. The application must be accompanied by a registration fee in the amount set under section 9(d) of this chapter. The commissioner shall deposit a registration fee collected under this subsection into the department of insurance fund established by IC 27-1-3-28.
(b) A certificate of registration issued under this chapter may not be transferred unless the department determines that the entity to whom the certificate is to be transferred has satisfied the requirements of this chapter.
(c) If there is a material change in any of the information set forth in an application submitted under this chapter, the utilization review agent that submitted the application shall notify the department of the change in writing within thirty (30) days after the change.
As added by P.L.128-1992, SEC.1. Amended by P.L.173-2007, SEC.40; P.L.234-2007, SEC.197; P.L.146-2015, SEC.36.
2023 Indiana Code › Title 27. Insurance › Article 8. Life, Accident, and Health › Chapter 17. Health Care Utilization Review › 27-8-17-11. Minimum Utilization Review Agent Requirements

Sec. 11. A utilization review agent must satisfy the following minimum requirements:
(1) Provide toll free telephone access at least forty (40) hours each week during normal business hours.
(2) Maintain a telephone call recording system capable of accepting or recording incoming telephone calls or providing instructions during hours other than normal business hours.
(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 of covered individuals.
(5) Within two (2) business days after receiving a request for a utilization review determination that includes all information necessary to complete the utilization review determination, notify the enrollee or the provider of record of the utilization review determination by mail or another means of communication.
(6) Include in the notification of a utilization review determination not to certify an admission, a service, or a procedure:
(A) if the determination not to certify is based on medical necessity or appropriateness of the admission, service, or procedure, the principal reason for that determination; and
(B) the procedures to initiate an appeal of the determination.
(7) Ensure that every utilization review determination as to the necessity or appropriateness of an admission, a service, or a procedure is:
(A) reviewed by a physician; or
(B) determined in accordance with standards or guidelines approved by a physician.
(8) Ensure that every physician making a utilization review determination for the utilization review agent has a current license issued by a state licensing agency in the United States.
(9) Provide a period of at least forty-eight (48) hours following an emergency admission, service, or procedure during which:
(A) an enrollee; or
(B) the representative of an enrollee;
may notify the utilization review agent and request certification or continuing treatment for the condition involved in the admission, service, or procedure.
(10) Provide an appeals procedure satisfying the requirements set forth in section 12 of this chapter.
(11) Develop a utilization review plan and file a summary of the plan with the department.
As added by P.L.128-1992, SEC.1.
2023 Indiana Code › Title 27. Insurance › Article 8. Life, Accident, and Health › Chapter 17. Health Care Utilization Review › 27-8-17-12. Appeals Procedure

Sec. 12. (a) A utilization review agent shall make available to an enrollee, and to a provider of record upon request, at the time an adverse utilization review determination is made:
(1) a written description of the appeals procedure by which an enrollee or a provider of record may appeal the utilization review determination by the utilization review agent; and
(2) in the case of an enrollee covered under an accident and sickness policy or a health maintenance organization contract described in subsection (d), notice that the enrollee has the right to appeal the utilization review determination under IC 27-8-28 or IC 27-13-10 and the toll free telephone number that the enrollee may call to request a review of the determination or obtain further information about the right to appeal.
(b) The appeals procedure provided by a utilization review agent must meet the following requirements:
(1) On appeal, the determination not to certify an admission, a service, or a procedure as necessary or appropriate must be made by a health care provider licensed in the same discipline as the provider of record.
(2) The determination of the appeal of a utilization review determination not to certify an admission, service, or procedure must be completed within thirty (30) days after:
(A) the appeal is filed; and
(B) all information necessary to complete the appeal is received.
(c) A utilization review agent shall provide an expedited appeals process for emergency or life threatening situations. The determination of an expedited appeal under the process required by this subsection shall be made by a physician and completed within forty-eight (48) hours after:
(1) the appeal is initiated; and
(2) all information necessary to complete the appeal is received by the utilization review agent.
(d) If an enrollee is covered under an accident and sickness insurance policy (as defined in IC 27-8-28-1) or a contract issued by a health maintenance organization (as defined in IC 27-13-1-19), the enrollee's exclusive right to appeal a utilization review determination is provided under IC 27-8-28 or IC 27-13-10, respectively.
(e) A utilization review agent shall make available upon request a written description of the appeals procedure that an enrollee or provider of record may use to obtain a review of a utilization review determination by the utilization review agent.
As added by P.L.128-1992, SEC.1. Amended by P.L.66-2001, SEC.1; P.L.203-2001, SEC.12; P.L.1-2002, SEC.112.
2023 Indiana Code › Title 27. Insurance › Article 8. Life, Accident, and Health › Chapter 17. Health Care Utilization Review › 27-8-17-13. Physician's Statement; Documentation of Review Agent Capability

Sec. 13. To provide documentation demonstrating that a utilization review agent is capable of satisfying the requirement of section 11(7) of this chapter, as required by section 9(b)(3) of this chapter, the utilization review agent may provide a signed statement of a physician employed by or under contract to the utilization review agent verifying that determinations made by the utilization review agent as to the necessity or appropriateness of admissions, services, and procedures are reviewed by a physician or determined in accordance with standards or guidelines approved by a physician.
As added by P.L.128-1992, SEC.1.
2023 Indiana Code › Title 27. Insurance › Article 8. Life, Accident, and Health › Chapter 17. Health Care Utilization Review › 27-8-17-14. Accreditation and Approval of Review Agent; Determination; New Certificate of Registration; Order to Cease Activities

Sec. 14. (a) The department may, according to the rules adopted under section 20 of this chapter, determine that a utilization review agent satisfies the requirements set forth in section 11 of this chapter if the utilization review agent:
(1) has, at the time of issuance of the agent's certificate of registration, received; and
(2) maintains;
the approval or accreditation of a utilization review accreditation organization that has been approved by the department for the purposes of this section. The department may not make a determination under this subsection before July 1, 1993.
(b) If a utilization review agent:
(1) is determined to satisfy the requirements of section 11 of this chapter by obtaining accreditation from a utilization review accreditation organization; and
(2) subsequently loses the accreditation from the accrediting organization;
the utilization review agent must, within sixty (60) days after losing its accreditation, obtain a new certificate of registration under this chapter to continue to conduct utilization review in Indiana. During the sixty (60) day period, the utilization review agent may continue to conduct utilization review subject to all other requirements of this chapter, unless ordered to cease under subsection (c).
(c) If the department determines, before the expiration of the sixty (60) day period referred to in subsection (b), that the utilization review agent cannot satisfy the requirements for issuance of a certificate of registration under this chapter, the department shall order the utilization review agent to immediately cease all utilization review activities in Indiana.
As added by P.L.128-1992, SEC.1.
2023 Indiana Code › Title 27. Insurance › Article 8. Life, Accident, and Health › Chapter 17. Health Care Utilization Review › 27-8-17-15. Certification of Admission, Service, or Procedure; Enrollee Request; Notice and Information; Assistance; Denial Under Terms of Benefit Program

Sec. 15. (a) The following requirements apply to an enrollee's request for certification by a utilization review agent of an admission, a service, or a procedure:
(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.
(2) A utilization review agent shall allow the provider of record or a responsible patient representative, including a family member, to assist the enrollee in fulfilling the enrollee's responsibility under subdivision (1).
(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.
2023 Indiana Code › Title 27. Insurance › Article 8. Life, Accident, and Health › Chapter 17. Health Care Utilization Review › 27-8-17-16. Fraudulent or Misleading Information; Penalties

Sec. 16. A provider of record, an enrollee, or the agent of a provider of record or an enrollee who provides fraudulent or misleading information is subject to appropriate administrative, civil, and criminal penalties, including criminal penalties under IC 35-43-5.
As added by P.L.128-1992, SEC.1. Amended by P.L.174-2021, SEC.25.
2023 Indiana Code › Title 27. Insurance › Article 8. Life, Accident, and Health › Chapter 17. Health Care Utilization Review › 27-8-17-17. Violations; Notice to Agent; Cease and Desist Orders; Penalties; Revocation or Suspension of Registration; Review

Sec. 17. (a) If the department believes that a utilization review agent has violated this chapter, the department shall notify the utilization review agent of the alleged violation.
(b) The utilization review agent shall respond to a notice given under subsection (a) within thirty (30) days after receiving the notice.
(c) If the department:
(1) believes that a utilization review agent has violated this chapter; and
(2) is not satisfied, based on the response given by the utilization review agent under subsection (b), that the violation has been corrected;
the department shall order the utilization review agent under IC 4-21.5-3-6 to cease all utilization review activities in Indiana.
(d) If the department determines that a utilization review agent has violated this chapter, the department:
(1) shall order the utilization review agent to cease and desist from engaging in the violation; and
(2) may do either or both of the following:
(A) Order the utilization review agent to pay a civil penalty of not more than five thousand dollars ($5,000) if the utilization review agent has committed violations with a frequency that indicates a general business practice.
(B) Suspend or revoke the certificate of registration of the utilization review agent.
(e) Any order issued or ruling made by the department under this section is subject to review under IC 4-21.5.
As added by P.L.128-1992, SEC.1.
2023 Indiana Code › Title 27. Insurance › Article 8. Life, Accident, and Health › Chapter 17. Health Care Utilization Review › 27-8-17-18. Confidential Information

Sec. 18. (a) This chapter does not require a utilization review agent to disclose information that is proprietary.
(b) Any:
(1) information concerning standards, criteria, or medical protocols used by a utilization review agent in conducting utilization review; or
(2) other proprietary information concerning utilization review conducted by a utilization review agent;
that is disclosed to the department of insurance under this chapter is confidential for the purposes of IC 5-14-3-4(a)(1) and may not be disclosed by the department.
As added by P.L.128-1992, SEC.1. Amended by P.L.1-1993, SEC.207.
2023 Indiana Code › Title 27. Insurance › Article 8. Life, Accident, and Health › Chapter 17. Health Care Utilization Review › 27-8-17-19. Prohibited Bases for Compensation of Agent

Sec. 19. The compensation of a utilization review agent for the performance of utilization review may not be based on:
(1) the extent to which certifications are denied; or
(2) the amount by which subsequent claims are reduced for payment.
As added by P.L.128-1992, SEC.1.
2023 Indiana Code › Title 27. Insurance › Article 8. Life, Accident, and Health › Chapter 18. Charitable Entity's Insurable Interest in Life of Donor › 27-8-18-1. Application of Chapter

Sec. 1. This chapter applies to every life insurance policy issued in Indiana or issued for delivery in Indiana, irrespective of the date of issue.
As added by P.L.129-1992, SEC.1.
2023 Indiana Code › Title 27. Insurance › Article 8. Life, Accident, and Health › Chapter 18. Charitable Entity's Insurable Interest in Life of Donor › 27-8-18-2. "Charitable Entity"

Sec. 2. As used in this chapter, "charitable entity" means an entity that is exempt from federal taxation under Section 501(c)(3) of the Internal Revenue Code (26 U.S.C. 501(c)(3)).
As added by P.L.129-1992, SEC.1. Amended by P.L.124-2018, SEC.83.
2023 Indiana Code › Title 27. Insurance › Article 8. Life, Accident, and Health › Chapter 18. Charitable Entity's Insurable Interest in Life of Donor › 27-8-18-3. "Life Insurance Policy"

Sec. 3. As used in this chapter, "life insurance policy" means an insurance policy that provides the type of insurance described in Class 1(a) of IC 27-1-5-1.
As added by P.L.129-1992, SEC.1.
2023 Indiana Code › Title 27. Insurance › Article 8. Life, Accident, and Health › Chapter 18. Charitable Entity's Insurable Interest in Life of Donor › 27-8-18-4. Purchase, Ownership, or Transfer of Ownership; Consent; Insurable Interest

Sec. 4. (a) A charitable entity may:
(1) purchase;
(2) own; or
(3) be transferred ownership of;
a life insurance policy on the life of an individual if the individual consents to the charitable entity's purchase or ownership of the policy.
(b) A charitable entity that purchases or is transferred ownership of a life insurance policy under subsection (a) has an insurable interest in the life of the individual who consents to the charitable entity's purchase or ownership of the policy.
As added by P.L.129-1992, SEC.1.
2023 Indiana Code › Title 27. Insurance › Article 8. Life, Accident, and Health › Chapter 18. Charitable Entity's Insurable Interest in Life of Donor › 27-8-18-5. Inquiry Into Legal Status of Charitable Entity

Sec. 5. A life insurance company that is requested to:
(1) issue a life insurance policy; or
(2) transfer ownership of a life insurance policy;
to an entity that is purported to be a charitable entity has no obligation to inquire into the legal status of that entity under any law.
As added by P.L.129-1992, SEC.1.
2023 Indiana Code › Title 27. Insurance › Article 8. Life, Accident, and Health › Chapter 18. Charitable Entity's Insurable Interest in Life of Donor › 27-8-18-6. Reliance on Good Faith Representations

Sec. 6. A life insurance company is entitled to rely on the representations made in apparent good faith by the owner or putative owner of a life insurance policy for the purpose of inducing the life insurance company to accept an entity as the owner or beneficiary of the life insurance policy.
As added by P.L.129-1992, SEC.1.
2023 Indiana Code › Title 27. Insurance › Article 8. Life, Accident, and Health › Chapter 19. Repealed

[Pre-1993 Title 16 Recodification Citations:
27-8-19-1formerly 16-10-8-127-8-19-2formerly 16-10-8-227-8-19-3formerly 16-10-8-3 part27-8-19-4formerly 16-10-8-3 part.]
Repealed by P.L.1-1994, SEC.137.
2023 Indiana Code › Title 27. Insurance › Article 8. Life, Accident, and Health › Chapter 19.8. Viatical Settlements › 27-8-19.8-1. "Applicant" Defined

Sec. 1. As used in this chapter, "applicant" refers to a person that applies for a viatical settlement provider license under this chapter.
As added by P.L.130-1994, SEC.47 and P.L.116-1994, SEC.70. Amended by P.L.32-1998, SEC.1; P.L.223-2005, SEC.3.
2023 Indiana Code › Title 27. Insurance › Article 8. Life, Accident, and Health › Chapter 19.8. Viatical Settlements › 27-8-19.8-2. "Department" Defined

Sec. 2. As used in this chapter, "department" refers to the department of insurance.
As added by P.L.130-1994, SEC.47 and P.L.116-1994, SEC.70.
2023 Indiana Code › Title 27. Insurance › Article 8. Life, Accident, and Health › Chapter 19.8. Viatical Settlements › 27-8-19.8-3. "Insured" Defined

Sec. 3. As used in this chapter, "insured" refers to an individual whose life is the subject of insurance under a life insurance policy or contract.
As added by P.L.130-1994, SEC.47 and P.L.116-1994, SEC.70. Amended by P.L.32-1998, SEC.2; P.L.223-2005, SEC.4.