See the bold text below:

Section 27-1-37.5-1. Application of Chapter

Sec. 1. (a) Except as provided in sections 10, 11, 12, and 13 of this chapter, this chapter applies beginning September 1, 2018.

(b) This chapter does not apply to a step therapy protocol exception procedure under IC 27-8-5-30 or IC 27-13-7-23.

(c) This chapter does not apply to a health plan that is offered by a local unit public employer under a program of group health insurance provided under IC 5-10-8-2.6.

Section 27-1-37.5-1.5.  “Adverse Determination”

Sec. 1.5. As used in this chapter, “adverse determination” means a denial of a request for benefits on the grounds that the health service or item:

(1) is not medically necessary, appropriate, effective, or efficient;

(2) is not being provided in or at an appropriate health care setting or level of care; or

(3) is experimental or investigational.

Section 27-1-37.5-1.5 was added by SB 400 (2023).  See https://iga.in.gov/legislative/2023/bills/senate/400/details

Section 27-1-37.5-1.7. “Clinical peer”

Sec. 1.7. As used in this chapter, “clinical peer” means a practitioner or other health care provider
who either:

(1) holds a current and valid license in any United States jurisdiction;

(2) has been granted reciprocity in the state, if reciprocity exists; or

(3) holds a license that is part of a compact in which the state has entered.

Section 27-1-37.5-1.7 was added by SB 400 (2023).  See https://iga.in.gov/legislative/2023/bills/senate/400/details

Section 27-1-37.5-2. “Covered individual”

Sec. 2. As used in this chapter, “covered individual” means an individual who is covered under a health plan.

Section 27-1-37.5-3. “Cpt Code”

Sec. 3. As used in this chapter, “CPT code” refers to the medical billing code that applies to a specific health care service, as published in the Current Procedural Terminology code set maintained by the American Medical Association.

Section 27-1-37.5-4. “Health Care Service”

Sec. 4. (a) As used in this chapter, “health care service” means a health care related service or product rendered or sold by a health care provider within the scope of the health care provider’s license or legal authorization, including hospital, medical, surgical, mental health, and substance abuse services or products.

(b) The term does not include the following:

(1) Dental services.

(2) Vision services.

(3) Long term rehabilitation treatment.

(4) Pharmaceutical services or products.

Section 27-1-37.5-5. “Health Plan”

Sec. 5. (a) As used in this chapter, “health plan” means any of the following that provides coverage for health care services:

(1) A policy of accident and sickness insurance (as defined in IC 27-8-5-1). However, the term does not include the coverages described in IC 27-8-5-2.5(a).

(2) A contract with a health maintenance organization (as defined in IC 27-13-1-19) that provides coverage for basic health care services (as defined in IC 27-13-1-4).

(3) After December 31, 2020, the Medicaid risk based managed care program under IC 12-15.

(b) The term includes a person that administers any of the following:

(1) A policy described in subsection (a)(1).

(2) A contract described in subsection (a)(2).

(3) A self-insurance program established under IC 5-10-8-7(b) to provide health care coverage.

(4) After December 31, 2020, Medicaid risk based managed care.

Section 27-1-37.5-6. “Participating Provider”

Sec. 6. As used in this chapter, “participating provider” refers to the following:

(1) A health care provider that has entered into an agreement with an insurer under IC 27-8-11-3.

(2) A participating provider (as defined in IC 27-13-1-24).

Section 27-1-37.5-7. “Prior Authorization”

Sec. 7. As used in this chapter, “prior authorization” means a practice implemented by a health plan through which coverage of a health care service is dependent on the covered individual or health care provider obtaining approval from the health plan before the health care service is rendered. The term includes prospective or utilization review procedures conducted before a health care service is rendered.

Section 27-1-37.5-8. “Urgent Care Situation”

Sec. 8. As used in this chapter, “urgent care situation” means a situation in which a covered individual’s treating physician has determined that the covered individual’s condition is likely to result in:

(1) adverse health consequences or serious jeopardy to the covered individual’s life, health, or safety; or

(2) due to the covered individual’s psychological state, serious jeopardy to the life, health, or safety of another individual;

unless treatment of the covered individual’s condition for which prior authorization is sought occurs earlier than the period generally considered by the medical profession to be reasonable to treat routine or non-life threatening conditions.

Section 27-1-37.5-9. Availability of Prior Authorization Information; Requirements; New Requirements; Address Change; Notices

Sec. 9. (a) A health plan shall make available to participating providers on the health plan’s Internet web site or portal the applicable CPT code for the specific health care services for which prior authorization is required.

(b) A health plan shall make available to participating providers, on the health plan’s Internet web site or portal, a list of the health plan’s prior authorization requirements, including specific information that a provider must submit to establish a complete request for prior authorization. This subsection does not prevent a health plan from requiring specific additional information upon review of the request for prior authorization.

Amendments

(c) A health plan shall, not less than forty-five (45) days before the prior authorization requirement becomes effective, disclose to a participating provider any new prior authorization requirement.

(d) A disclosure made under subsection (c) must:

(1) be sent via electronic or United States mail and conspicuously labeled “Notice of Changes to Prior Authorization Requirements”; and

(2) specifically identify the location on the health plan’s Internet web site or portal of the new prior authorization requirement.

However, a health plan is considered to have met the requirements of this subsection if the health plan conspicuously posts the information required by this subsection, including the effective date of the new prior authorization requirement, on the health plan’s Internet web site.

(e) A participating provider shall, not more than seven (7) days after the change is made, notify the health plan of a change in the participating provider’s electronic or United States mail address.

Section 27-1-37.5-10. Request for Prior Authorization; Electronic Transmission; Standardized Form

Sec. 10. (a) This section applies to a request for prior authorization delivered to a health plan after December 31, 2019.

(b) A health plan shall accept a request for prior authorization delivered to the health plan by a covered individual’s health care provider through a secure electronic transmission. A health care provider shall submit a request for prior authorization through a secure electronic transmission. A health plan shall provide for:

(1) a secure electronic transmission; and

(2) acknowledgment of receipt, by use of a transaction number or another reference code;

of a request for prior authorization and any supporting information.

(c) Subsection (b) does not apply and a health plan that requires prior authorization shall accept a request for prior authorization that is not submitted through a secure electronic transmission if a covered individual’s health care provider and the health plan have entered into an agreement under which the health plan agrees to process prior authorization requests that are not submitted through a secure electronic transmission because:

(1) secure electronic transmission of prior authorization requests would cause financial hardship for the health care provider;

(2) the area in which the health care provider is located lacks sufficient Internet access; or

(3) the health care provider has an insufficient number of covered individuals as patients or customers, as determined by the commissioner, to warrant the financial expense that compliance with subsection (b) would require.

(d) If a covered individual’s health care provider is described in subsection (c), the health plan shall accept from the health care provider a request for prior authorization as follows:

(1) The prior authorization request must be made on the standardized prior authorization form established by the department under section 16 of this chapter.

(2) The health plan shall provide for secure electronic transmission and acknowledgement of receipt of the standardized prior authorization form and any supporting information for the prior authorization by use of a transaction number or another reference code.

Section 27-1-37.5-11. Response to Request for Prior Authorization; Timing; Incomplete Request

Sec. 11. (a) This section applies to a prior authorization request delivered to a health plan after December 31, 2019.

(b) A health plan shall respond to a request delivered under section 10 of this chapter as follows:

(1) If the request is delivered under section 10(b) of this chapter, the health plan shall immediately send to the requesting health care provider an electronic receipt for the request.

State Medical Necessity Decisions-Deadlines

(2) If the request is for an urgent care situation, the health plan shall respond with a prior authorization determination not more than forty-eight (48) hours after receiving the request.

(3) If the request is for a nonurgent care situation, the health plan shall respond with a prior authorization determination not more than five (5) business days after receiving the request.

(c) If a request delivered under section 10 of this chapter is incomplete:

(1) the health plan shall respond within the period required by subsection (b) and indicate the specific additional information required to process the request;

(2) if the request was delivered under section 10(b) of this chapter, upon receiving the response under subdivision (1), the health care provider shall immediately send to the health plan an electronic receipt for the response made under subdivision (1); and

(3) if the request is for an urgent care situation, the health care provider shall respond to the request for additional information not more than forty-eight (48) hours after the health care provider receives the response under subdivision (1).

(d) If a request delivered under section 10 of this chapter is denied, the health plan shall respond within the period required by subsection (b) and indicate the specific reason for the denial in clear and easy to understand language.

Section 27-1-37.5-11 was amended by SB 400 (2023).  See https://iga.in.gov/legislative/2023/bills/senate/400/details

Retroactive Denial

Section27-1-37.5-12. Claim for Which Prior Authorization Was Given; Denial; Resubmission of Claim 

Sec. 12. (a) This section applies to a claim for a health care service rendered by a participating provider:

(1) for which:

(A) prior authorization is requested after December 31, 2019; and

(B) a health plan gives prior authorization; and

(2) that is rendered in accordance with:

(A) the prior authorization; and

(B) all terms and conditions of the participating provider’s agreement or contract with the health plan.

(b) The health plan shall not deny the claim described in subsection (a) unless:

(1) the:

(A) request for prior authorization; or

(B) claim;

contains fraudulent or materially incorrect information; or

(2) the covered individual is not covered under the health plan on the date on which the health care service is rendered.

(c) If:

(1) the claim described in subsection (a) contains an unintentional and inaccurate inconsistency with the request for prior authorization; and

(2) the inconsistency results in denial of the claim;

the health care provider may resubmit the claim with accurate, corrected information.

Section 27-1-37.5-13. Unanticipated, Medically Necessary Health Care Service; Denial; Payment for Health Care Service With Prior Authorization

Sec. 13. (a) This section applies to a claim filed after December 31, 2018, for a medically necessary health care service rendered by a participating provider, the necessity of which:

(1) is not anticipated at the time prior authorization is obtained for another health care service; and

(2) is determined at the time the other health care service is rendered.

(b) The health plan shall not deny a claim described in subsection (a) based solely on lack of prior authorization for the unanticipated health care service.

(c) The health plan:

(1) shall not deny payment for a health care service that is rendered in accordance with:

(A) a prior authorization; and

(B) all terms and conditions of the participating provider’s agreement or contract with the health plan; and

(2) may:

(A) require retrospective review of; and

(B) withhold payment for;

an unanticipated health care service described in subsection (a).

Section 27-1-37.5-13.5. CPT codes exempt from prior authorization

(a) This section applies only to the state employee health plan (as defined in IC 5-10-8-6.7(a)).

(b) The state employee health plan may not require a participating provider to obtain prior authorization for the following CPT codes:

(1) 11200.
(2) 11201.
(3) 17311.
(4) 17312.
(5) 17313.
(6) 17314.
(7) 44140.
(8) 44160.
(9) 44970.
(10) 49505.
(11) 70450.
(12) 70551.
(13) 70552.
(14) 70553.
(15) 71250.
(16) 71260.
(17) 71275.
(18) 72141.
(19) 72148.
(20) 72158.
(21) 73221.
(22) 73721.
(23) 74150.
(24) 74160.
(25) 74176.
(26) 74177.
(27) 74178.
(28) 74179.
(29) 74181.
(30) 74183.
(31) 78452.
(32) 92507.

(33) 92526.
(34) 92609.
(35) 93303.
(36) 93306.
(37) 95044.
(38) 95806.
(39) 95810.
(40) 97110.
(41) 97112.
(42) 97116.
(43) 97129.
(44) 97130.
(45) 97140.
(46) 97530.
(47) V5010.
(48) V5256.
(49) V5261.
(50) V5275.

(c) The state employee health plan may not issue a retroactive denial for medical necessity for a CPT code listed in subsection (b).

(d) Before November 1, 2025, the:

(1) interim study committee on public health, behavioral health, and human services; and

(2) interim study committee on financial institutions and insurance;

shall jointly review the impact of this section, including any relief on the administrative burdens to participating providers and any differences in utilization of the CPT codes listed in subsection (b).

(e) This section expires June 30, 2026.

Section 27-1-37.5-13.5 was added by SB 400 (2023).  See https://iga.in.gov/legislative/2023/bills/senate/400/details

Section 27-1-37.5-14. Contrary Contract Provision Void

Sec. 14. A provision that:

(1) is contained in a policy or contract that is entered into, amended, or renewed after June 30, 2018; and

(2) contradicts this chapter;

is void.

Section 27-1-37.5-17.  Peer to peer review

(a) As used in this section, “necessary information” includes the results of any face-to-face
clinical evaluation, second opinion, or other clinical information that is directly applicable to the requested service that may be required.

(b) If a health plan makes an adverse determination on a prior authorization request by a covered individual’s health care provider, the health plan must offer the covered individual’s health care provider the option to request a peer to peer review by a clinical peer concerning the adverse determination.

(c) A covered individual’s health care provider may request a peer to peer review by a clinical peer either in writing or electronically.

(d) If a peer to peer review by a clinical peer is requested under this section:

(1) the health plan’s clinical peer and the covered individual’s health care provider or the health care provider’s designee shall make every effort to provide the peer to peer review not later than seven (7) business days from the date of receipt by the health plan of the request by the covered individual’s health care provider for a peer to peer review if the health plan has received the necessary information for the peer to peer review; and

(2) the health plan must have the peer to peer review conducted between the clinical peer and the covered individual’s health care provider or the provider’s designee.

Section 27-1-37.5-17 was added by SB 400 (2023).  See https://iga.in.gov/legislative/2023/bills/senate/400/details

Unless otherwise noted by references to HB 400 (2023) these laws may be accessed at https://law.justia.com/codes/indiana/2022/title-27/article-1/chapter-37-5/