Indiana 2025 Regular Session

Indiana Senate Bill SB0480 Compare Versions

Version 1 (Old)

Version 2 (New)

Old	New		Differences
	1	+	ES0480.2
	2	+	Reprinted
	3	+	April 11, 2025
	4	+	ENGROSSED
	5	+	SENATE BILL No. 480
	6	+	_____
	7	+	DIGEST OF SB 480 (Updated April 10, 2025 1:22 pm - DI 141)
	8	+	Citations Affected: IC 5-10; IC 27-1; IC 27-8; IC 27-13.
	9	+	Synopsis: Prior authorization. Sets forth requirements for a utilization
	10	+	review entity that requires prior authorization of a health care service.
	11	+	Prohibits a utilization review entity from requiring prior authorization
	12	+	for the first 12 physical therapy or chiropractic visits of each new
	13	+	episode of care. Provides that a claim for reimbursement for a covered
	14	+	service or item provided to an insured or enrollee may not be denied on
	15	+	the sole basis that the referring provider is an out of network provider.
	16	+	Repeals superseded provisions regarding prior authorization. Makes
	17	+	corresponding changes.
	18	+	Effective: July 1, 2025.
	19	+	Johnson T, Charbonneau, Brown L, Rogers, Crider,
	20	+	Becker, Leising, Hunley, Ford J.D., Alexander, Bassler,
	21	+	Bohacek, Buchanan, Byrne, Dernulc, Donato, Koch,
	22	+	Maxwell, Randolph Lonnie M, Buck, Busch, Doriot,
	23	+	Walker K, Yoder, Pol Jr., Zay, Clark, Qaddoura, Alting,
	24	+	Deery, Glick, Holdman, Jackson L, Niemeyer, Niezgodski,
	25	+	Raatz, Spencer, Taylor G, Walker G, Tomes, Carrasco,
	26	+	Schmitt, Young M
	27	+	(HOUSE SPONSORS — BARRETT, CARBAUGH, MCGUIRE, KING)
	28	+	January 13, 2025, read first time and referred to Committee on Health and Provider
	29	+	Services
	30	+	January 23, 2025, reported favorably — Do Pass; reassigned to Committee on
	31	+	Appropriations.
	32	+	February 13, 2025, amended, reported favorably — Do Pass.
	33	+	February 17, 2025, read second time, ordered engrossed. Engrossed.
	34	+	February 20, 2025, read third time, passed. Yeas 47, nays 2.
	35	+	HOUSE ACTION
	36	+	March 3, 2025, read first time and referred to Committee on Insurance.
	37	+	April 8, 2025, amended, reported — Do Pass.
	38	+	April 10, 2025, read second time, amended, ordered engrossed.
	39	+	ES 480—LS 7146/DI 141 Reprinted
	40	+	April 11, 2025
1	41		First Regular Session of the 124th General Assembly (2025)
2	42		PRINTING CODE. Amendments: Whenever an existing statute (or a section of the Indiana
3	43		Constitution) is being amended, the text of the existing provision will appear in this style type,
4	44		additions will appear in this style type, and deletions will appear in this style type.
5	45		Additions: Whenever a new statutory provision is being enacted (or a new constitutional
6	46		provision adopted), the text of the new provision will appear in this style type. Also, the
7	47		word NEW will appear in that style type in the introductory clause of each SECTION that adds
8	48		a new provision to the Indiana Code or the Indiana Constitution.
9	49		Conflict reconciliation: Text in a statute in this style type or this style type reconciles conflicts
10	50		between statutes enacted by the 2024 Regular Session of the General Assembly.
11		-	SENATE ENROLLED ACT No. 480
12		-	AN ACT to amend the Indiana Code concerning insurance.
	51	+	ENGROSSED
	52	+	SENATE BILL No. 480
	53	+	A BILL FOR AN ACT to amend the Indiana Code concerning
	54	+	insurance.
13	55		Be it enacted by the General Assembly of the State of Indiana:
14		-	SECTION 1. IC 5-10-8-19, AS ADDED BY P.L.77-2018,
15		-	SECTION 1, IS AMENDED TO READ AS FOLLOWS [EFFECTIVE
16		-	JULY 1, 2025]: Sec. 19. A self-insurance program established under
17		-	section 7(b) of this chapter to provide health care coverage shall
18		-	comply with the prior authorization requirements that apply to a health
19		-	plan utilization review entity under IC 27-1-37.5.
20		-	SECTION 2. IC 27-1-37.5-1, AS AMENDED BY P.L.190-2023,
21		-	SECTION 13, IS AMENDED TO READ AS FOLLOWS [EFFECTIVE
22		-	JULY 1, 2025]: Sec. 1. (a) Except as provided in sections 10, 11, 12,
23		-	13, and 13.5 of this chapter, this chapter applies beginning September
24		-	1, 2018.
25		-	(b) (a) This chapter does not apply to a step therapy protocol
26		-	exception procedure under IC 5-10-8-17, IC 27-8-5-30, or
27		-	IC 27-13-7-23.
28		-	(c) (b) This chapter does not apply to a health plan that is offered by
29		-	a local unit public employer under a program of group health insurance
30		-	provided under IC 5-10-8-2.6.
31		-	(c) This chapter does not apply to health care services provided
32		-	under the following state Medicaid waivers:
33		-	(1) Pathways for aging.
34		-	(2) Health and wellness.
35		-	(d) This chapter does not apply to the extent that it is preempted
36		-	SEA 480 — Concur 2
37		-	by a federal statute or regulation relating to the Medicaid program
38		-	under Title XIX of the federal Social Security Act (42 U.S.C. 1396
39		-	et seq.).
40		-	SECTION 3. IC 27-1-37.5-1.5, AS ADDED BY P.L.190-2023,
41		-	SECTION 14, IS AMENDED TO READ AS FOLLOWS [EFFECTIVE
42		-	JULY 1, 2025]: Sec. 1.5. As used in this chapter, "adverse
43		-	determination" means a denial of a request for benefits decision by a
44		-	utilization review entity to deny, reduce, or terminate benefit
45		-	coverage of a health care service furnished or proposed to be
46		-	furnished to a covered individual on the grounds that the health care
47		-	service: or item:
48		-	(1) is not medically necessary, appropriate, effective, or efficient;
49		-	(2) is not being provided in or at an appropriate health care setting
50		-	or level of care; or
51		-	(3) is experimental or investigational.
52		-	SECTION 4. IC 27-1-37.5-1.6 IS ADDED TO THE INDIANA
53		-	CODE AS A NEW SECTION TO READ AS FOLLOWS
54		-	[EFFECTIVE JULY 1, 2025]: Sec. 1.6. As used in this chapter,
55		-	"authorization" means a determination by a utilization review
56		-	entity that:
57		-	(1) a health care service:
58		-	(A) has been reviewed; and
59		-	(B) based on the information provided, satisfies the
60		-	utilization review entity's requirements for medical
61		-	necessity; and
62		-	(2) payment will be made for the health care service.
63		-	SECTION 5. IC 27-1-37.5-1.7, AS ADDED BY P.L.190-2023,
	56	+	1 SECTION 1. IC 5-10-8-19, AS ADDED BY P.L.77-2018,
	57	+	2 SECTION 1, IS AMENDED TO READ AS FOLLOWS [EFFECTIVE
	58	+	3 JULY 1, 2025]: Sec. 19. A self-insurance program established under
	59	+	4 section 7(b) of this chapter to provide health care coverage shall
	60	+	5 comply with the prior authorization requirements that apply to a health
	61	+	6 plan utilization review entity under IC 27-1-37.5.
	62	+	7 SECTION 2. IC 27-1-37.5-1, AS AMENDED BY P.L.190-2023,
	63	+	8 SECTION 13, IS AMENDED TO READ AS FOLLOWS [EFFECTIVE
	64	+	9 JULY 1, 2025]: Sec. 1. (a) Except as provided in sections 10, 11, 12,
	65	+	10 13, and 13.5 of this chapter, this chapter applies beginning September
	66	+	11 1, 2018.
	67	+	12 (b) (a) This chapter does not apply to a step therapy protocol
	68	+	13 exception procedure under IC 5-10-8-17, IC 27-8-5-30, or
	69	+	14 IC 27-13-7-23.
	70	+	15 (c) (b) This chapter does not apply to a health plan that is offered by
	71	+	16 a local unit public employer under a program of group health insurance
	72	+	17 provided under IC 5-10-8-2.6.
	73	+	ES 480—LS 7146/DI 141 2
	74	+	1 (c) This chapter does not apply to health care services provided
	75	+	2 under the following state Medicaid waivers:
	76	+	3 (1) Pathways for aging.
	77	+	4 (2) Health and wellness.
	78	+	5 (d) This chapter does not apply to the extent that it is preempted
	79	+	6 by a federal statute or regulation relating to the Medicaid program
	80	+	7 under Title XIX of the federal Social Security Act (42 U.S.C. 1396
	81	+	8 et seq.).
	82	+	9 SECTION 3. IC 27-1-37.5-1.5, AS ADDED BY P.L.190-2023,
	83	+	10 SECTION 14, IS AMENDED TO READ AS FOLLOWS [EFFECTIVE
	84	+	11 JULY 1, 2025]: Sec. 1.5. As used in this chapter, "adverse
	85	+	12 determination" means a denial of a request for benefits decision by a
	86	+	13 utilization review entity to deny, reduce, or terminate benefit
	87	+	14 coverage of a health care service furnished or proposed to be
	88	+	15 furnished to a covered individual on the grounds that the health care
	89	+	16 service: or item:
	90	+	17 (1) is not medically necessary, appropriate, effective, or efficient;
	91	+	18 (2) is not being provided in or at an appropriate health care setting
	92	+	19 or level of care; or
	93	+	20 (3) is experimental or investigational.
	94	+	21 SECTION 4. IC 27-1-37.5-1.6 IS ADDED TO THE INDIANA
	95	+	22 CODE AS A NEW SECTION TO READ AS FOLLOWS
	96	+	23 [EFFECTIVE JULY 1, 2025]: Sec. 1.6. As used in this chapter,
	97	+	24 "authorization" means a determination by a utilization review
	98	+	25 entity that:
	99	+	26 (1) a health care service:
	100	+	27 (A) has been reviewed; and
	101	+	28 (B) based on the information provided, satisfies the
	102	+	29 utilization review entity's requirements for medical
	103	+	30 necessity; and
	104	+	31 (2) payment will be made for the health care service.
	105	+	32 SECTION 5. IC 27-1-37.5-1.7, AS ADDED BY P.L.190-2023,
	106	+	33 SECTION 15, IS AMENDED TO READ AS FOLLOWS [EFFECTIVE
	107	+	34 JULY 1, 2025]: Sec. 1.7. As used in this chapter, "clinical peer" means
	108	+	35 a practitioner or other health care provider who either: the following:
	109	+	36 (1) Except as provided in subdivision (3), for a review of a
	110	+	37 request from a physician, a physician who:
	111	+	38 (A) holds a current and valid license in any United States
	112	+	39 jurisdiction; under IC 25-22.5, (2) has been granted
	113	+	40 reciprocity in the state, under IC 25-1-21, if reciprocity exists,
	114	+	41 or (3) holds a license that is part of a compact in which the
	115	+	42 state Indiana has entered;
	116	+	ES 480—LS 7146/DI 141 3
	117	+	1 (B) is certified in the same specialty as the physician under
	118	+	2 review, as recognized by:
	119	+	3 (i) the American Board of Medical Specialties; or
	120	+	4 (ii) the American Osteopathic Association; and
	121	+	5 (C) if the review specifically concerns subspecialty care, is
	122	+	6 certified in the same subspecialty as the physician under
	123	+	7 review, as recognized by:
	124	+	8 (i) the American Board of Medical Specialties; or
	125	+	9 (ii) the American Osteopathic Association.
	126	+	10 (2) For a review of a request from an advanced practice
	127	+	11 registered nurse, an advanced practice registered nurse who:
	128	+	12 (A) holds a current and valid license under IC 25-23-1 or
	129	+	13 has been granted reciprocity under IC 25-1-21, if
	130	+	14 reciprocity exists, or holds a license that is part of a
	131	+	15 compact in which Indiana has entered; and
	132	+	16 (B) holds equivalent or similar:
	133	+	17 (i) population focus; and
	134	+	18 (ii) role specialty;
	135	+	19 as the advanced practice registered nurse who is subject to
	136	+	20 the review.
	137	+	21 (3) For a review of a request from a primary care physician
	138	+	22 (as defined in IC 25-22.5-5.5-1.5), a physician who:
	139	+	23 (A) holds a current and valid license under IC 25-22.5, has
	140	+	24 been granted reciprocity under IC 25-1-21, if reciprocity
	141	+	25 exists, or holds a license that is part of a compact in which
	142	+	26 Indiana has entered;
	143	+	27 (B) is certified in the same general practice of medicine
	144	+	28 under review, as recognized by:
	145	+	29 (i) the American Board of Medical Specialties;
	146	+	30 (ii) the American Board of Pediatrics; or
	147	+	31 (iii) the American Osteopathic Association; and
	148	+	32 (C) has been actively engaged in general practice for at
	149	+	33 least three (3) years.
	150	+	34 (4) For a review of a request from a practitioner or health
	151	+	35 care provider other than those specified in subdivisions (1)
	152	+	36 through (3), a practitioner or health care provider who:
	153	+	37 (A) holds a current and valid license in Indiana;
	154	+	38 (B) has been granted reciprocity in Indiana, if reciprocity
	155	+	39 exists; or
	156	+	40 (C) holds a license that is part of a compact in which
	157	+	41 Indiana has entered.
	158	+	42 SECTION 6. IC 27-1-37.5-1.8 IS ADDED TO THE INDIANA
	159	+	ES 480—LS 7146/DI 141 4
	160	+	1 CODE AS A NEW SECTION TO READ AS FOLLOWS
	161	+	2 [EFFECTIVE JULY 1, 2025]: Sec. 1.8. As used in this chapter,
	162	+	3 "clinical criteria" means:
	163	+	4 (1) written policies;
	164	+	5 (2) written screen procedures;
	165	+	6 (3) drug formularies or lists of covered drugs;
	166	+	7 (4) determination rules;
	167	+	8 (5) determination abstracts;
	168	+	9 (6) clinical protocols;
	169	+	10 (7) practice guidelines;
	170	+	11 (8) medical protocols; and
	171	+	12 (9) any other criteria or rationale;
	172	+	13 used by the utilization review entity to determine the medical
	173	+	14 necessity of a health care service.
	174	+	15 SECTION 7. IC 27-1-37.5-1.9 IS ADDED TO THE INDIANA
	175	+	16 CODE AS A NEW SECTION TO READ AS FOLLOWS
	176	+	17 [EFFECTIVE JULY 1, 2025]: Sec. 1.9. (a) As used in this chapter,
	177	+	18 "cosmetic surgery" means any procedure that:
	178	+	19 (1) is directed at improving the patient's appearance; and
	179	+	20 (2) does not meaningfully:
	180	+	21 (A) promote the proper function of the body; or
	181	+	22 (B) prevent or treat illness or disease.
	182	+	23 (b) The term does not include the following:
	183	+	24 (1) A procedure that is necessary to ameliorate a deformity
	184	+	25 arising from or directly related to a:
	185	+	26 (A) congenital abnormality;
	186	+	27 (B) personal injury resulting from an accident or trauma;
	187	+	28 or
	188	+	29 (C) disfiguring disease.
	189	+	30 (2) A procedure related to the treatment of breast cancer.
	190	+	31 SECTION 8. IC 27-1-37.5-2, AS ADDED BY P.L.77-2018,
	191	+	32 SECTION 2, IS AMENDED TO READ AS FOLLOWS [EFFECTIVE
	192	+	33 JULY 1, 2025]: Sec. 2. As used in this chapter, "covered individual"
	193	+	34 means an individual who is covered under a health plan. The term
	194	+	35 includes a covered individual's legally authorized representative.
	195	+	36 SECTION 9. IC 27-1-37.5-3.7 IS ADDED TO THE INDIANA
	196	+	37 CODE AS A NEW SECTION TO READ AS FOLLOWS
	197	+	38 [EFFECTIVE JULY 1, 2025]: Sec. 3.7. As used in this chapter,
	198	+	39 "emergency health care service" means a health care service that
	199	+	40 is provided in an emergency facility after the sudden onset of a
	200	+	41 medical condition that manifests itself by symptoms of sufficient
	201	+	42 severity, including severe pain, that the absence of immediate
	202	+	ES 480—LS 7146/DI 141 5
	203	+	1 medical attention could reasonably be expected by a prudent
	204	+	2 layperson who possesses average knowledge of health and medicine
	205	+	3 to:
	206	+	4 (1) place an individual's health in serious jeopardy;
	207	+	5 (2) result in serious impairment to the individual's bodily
	208	+	6 function; or
	209	+	7 (3) result in serious dysfunction of any bodily organ or part of
	210	+	8 the individual.
	211	+	9 SECTION 10. IC 27-1-37.5-3.8 IS ADDED TO THE INDIANA
	212	+	10 CODE AS A NEW SECTION TO READ AS FOLLOWS
	213	+	11 [EFFECTIVE JULY 1, 2025]: Sec. 3.8. As used in this chapter,
	214	+	12 "episode of care" means the medical care ordered to be provided
	215	+	13 for a specific medical procedure, condition, or illness.
	216	+	14 SECTION 11. IC 27-1-37.5-3.9 IS ADDED TO THE INDIANA
	217	+	15 CODE AS A NEW SECTION TO READ AS FOLLOWS
	218	+	16 [EFFECTIVE JULY 1, 2025]: Sec. 3.9. (a) As used in this chapter,
	219	+	17 except as provided in subsection (b), "health care provider" means
	220	+	18 an individual who holds a license issued by a board described in
	221	+	19 IC 25-0.5-11.
	222	+	20 (b) The term does not include the following:
	223	+	21 (1) A dentist licensed under IC 25-14.
	224	+	22 (2) An optometrist licensed under IC 25-24.
	225	+	23 (3) A veterinarian licensed under IC 25-38.1.
	226	+	24 SECTION 12. IC 27-1-37.5-4, AS ADDED BY P.L.77-2018,
	227	+	25 SECTION 2, IS AMENDED TO READ AS FOLLOWS [EFFECTIVE
	228	+	26 JULY 1, 2025]: Sec. 4. (a) As used in this chapter, "health care service"
	229	+	27 means a health care related service or product rendered or sold
	230	+	28 procedure, treatment, or service provided by:
	231	+	29 (1) a health care facility (as defined in IC 16-18-2-161(a));
	232	+	30 (2) an ambulatory outpatient surgical center (as defined in
	233	+	31 IC 16-18-2-14); or
	234	+	32 (3) a health care provider within the scope of practice of the
	235	+	33 health care provider's license or legal authorization.
	236	+	34 including hospital, medical, surgical, mental health, and substance
	237	+	35 abuse services or products. The term includes the provision of
	238	+	36 pharmaceutical products or services or durable medical
	239	+	37 equipment.
	240	+	38 (b) The term does not include the following:
	241	+	39 (1) Dental services.
	242	+	40 (2) Vision services.
	243	+	41 (3) Long term rehabilitation treatment. Cosmetic surgery.
	244	+	42 (4) Pharmaceutical services or products.
	245	+	ES 480—LS 7146/DI 141 6
	246	+	1 SECTION 13. IC 27-1-37.5-5.4 IS ADDED TO THE INDIANA
	247	+	2 CODE AS A NEW SECTION TO READ AS FOLLOWS
	248	+	3 [EFFECTIVE JULY 1, 2025]: Sec. 5.4. As used in this chapter,
	249	+	4 "medically necessary" means a health care service that a prudent
	250	+	5 health care provider would provide to a patient for the purpose of
	251	+	6 preventing, diagnosing, or treating an illness, injury, disease, or
	252	+	7 symptoms in a manner that is:
	253	+	8 (1) in accordance with generally accepted standards of
	254	+	9 medical practice;
	255	+	10 (2) clinically appropriate in terms of type, frequency, extent,
	256	+	11 site, and duration; and
	257	+	12 (3) not primarily for:
	258	+	13 (A) the economic benefit of the health plan or purchaser;
	259	+	14 or
	260	+	15 (B) the convenience of the health plan, patient, treating
	261	+	16 physician, or other health care provider.
	262	+	17 SECTION 14. IC 27-1-37.5-7, AS ADDED BY P.L.77-2018,
	263	+	18 SECTION 2, IS AMENDED TO READ AS FOLLOWS [EFFECTIVE
	264	+	19 JULY 1, 2025]: Sec. 7. As used in this chapter, "prior authorization"
	265	+	20 means a practice implemented by a health plan through which coverage
	266	+	21 of a health care service is dependent on the covered individual or
	267	+	22 health care provider obtaining approval from the health plan before the
	268	+	23 health care service is rendered. The term includes prospective or
	269	+	24 utilization review procedures conducted before a health care service is
	270	+	25 rendered. the process by which a utilization review entity
	271	+	26 determines the medical necessity of an otherwise covered health
	272	+	27 care service before the health care service is rendered. The term
	273	+	28 includes a utilization review entity's requirement that a covered
	274	+	29 individual or health care provider notify the utilization review
	275	+	30 entity prior to providing a health care service.
	276	+	31 SECTION 15. IC 27-1-37.5-8 IS REPEALED [EFFECTIVE JULY
	277	+	32 1, 2025]. Sec. 8. As used in this chapter, "urgent care situation" means
	278	+	33 a situation in which a covered individual's treating physician has
	279	+	34 determined that the covered individual's condition is likely to result in:
	280	+	35 (1) adverse health consequences or serious jeopardy to the
	281	+	36 covered individual's life, health, or safety; or
	282	+	37 (2) due to the covered individual's psychological state, serious
	283	+	38 jeopardy to the life, health, or safety of another individual;
	284	+	39 unless treatment of the covered individual's condition for which prior
	285	+	40 authorization is sought occurs earlier than the period generally
	286	+	41 considered by the medical profession to be reasonable to treat routine
	287	+	42 or non-life threatening conditions.
	288	+	ES 480—LS 7146/DI 141 7
	289	+	1 SECTION 16. IC 27-1-37.5-8.1 IS ADDED TO THE INDIANA
	290	+	2 CODE AS A NEW SECTION TO READ AS FOLLOWS
	291	+	3 [EFFECTIVE JULY 1, 2025]: Sec. 8.1. As used in this chapter,
	292	+	4 "urgent health care service" means a health care service in which
	293	+	5 the application of the time period for making a nonexpedited prior
	294	+	6 authorization, in the opinion of a physician with knowledge of the
	295	+	7 covered individual's medical condition, could:
	296	+	8 (1) seriously jeopardize:
	297	+	9 (A) the life or health of the covered individual; or
	298	+	10 (B) the covered individual's ability to regain maximum
	299	+	11 function; or
	300	+	12 (2) subject the covered individual to severe pain that cannot
	301	+	13 be adequately managed without the health care service.
	302	+	14 The term includes a mental and behavioral health care service.
	303	+	15 SECTION 17. IC 27-1-37.5-8.3 IS ADDED TO THE INDIANA
	304	+	16 CODE AS A NEW SECTION TO READ AS FOLLOWS
	305	+	17 [EFFECTIVE JULY 1, 2025]: Sec. 8.3. As used in this chapter,
	306	+	18 "utilization review entity" means an individual or entity that
	307	+	19 performs prior authorization for one (1) or more of the following:
	308	+	20 (1) An employer who employs a covered individual.
	309	+	21 (2) A health plan.
	310	+	22 (3) A preferred provider organization.
	311	+	23 (4) Any other individual or entity that:
	312	+	24 (A) provides;
	313	+	25 (B) offers to provide; or
	314	+	26 (C) administers;
	315	+	27 hospital, outpatient, medical, prescription drug, or other
	316	+	28 health benefits to a covered individual.
	317	+	29 SECTION 18. IC 27-1-37.5-9 IS REPEALED [EFFECTIVE JULY
	318	+	30 1, 2025]. Sec. 9. (a) A health plan shall make available to participating
	319	+	31 providers on the health plan's Internet web site or portal the applicable
	320	+	32 CPT code for the specific health care services for which prior
	321	+	33 authorization is required.
	322	+	34 (b) A health plan shall make available to participating providers, on
	323	+	35 the health plan's Internet web site or portal, a list of the health plan's
	324	+	36 prior authorization requirements, including specific information that a
	325	+	37 provider must submit to establish a complete request for prior
	326	+	38 authorization. This subsection does not prevent a health plan from
	327	+	39 requiring specific additional information upon review of the request for
	328	+	40 prior authorization.
	329	+	41 (c) A health plan shall, not less than forty-five (45) days before the
	330	+	42 prior authorization requirement becomes effective, disclose to a
	331	+	ES 480—LS 7146/DI 141 8
	332	+	1 participating provider any new prior authorization requirement.
	333	+	2 (d) A disclosure made under subsection (c) must:
	334	+	3 (1) be sent via electronic or United States mail and conspicuously
	335	+	4 labeled "Notice of Changes to Prior Authorization Requirements";
	336	+	5 and
	337	+	6 (2) specifically identify the location on the health plan's Internet
	338	+	7 web site or portal of the new prior authorization requirement.
	339	+	8 However, a health plan is considered to have met the requirements of
	340	+	9 this subsection if the health plan conspicuously posts the information
	341	+	10 required by this subsection, including the effective date of the new
	342	+	11 prior authorization requirement, on the health plan's Internet web site.
	343	+	12 (e) A participating provider shall, not more than seven (7) days after
	344	+	13 the change is made, notify the health plan of a change in the
	345	+	14 participating provider's electronic or United States mail address.
	346	+	15 SECTION 19. IC 27-1-37.5-10, AS ADDED BY P.L.208-2018,
	347	+	16 SECTION 8, IS AMENDED TO READ AS FOLLOWS [EFFECTIVE
	348	+	17 JULY 1, 2025]: Sec. 10. (a) This section applies to a request for prior
	349	+	18 authorization delivered to a health plan after December 31, 2019. does
	350	+	19 not apply to prior authorization for a prescription drug.
	351	+	20 (b) A health plan utilization review entity shall accept a request for
	352	+	21 prior authorization delivered to the health plan utilization review
	353	+	22 entity by a covered individual's health care provider through a secure
	354	+	23 electronic transmission or an application programming interface. A
	355	+	24 health care provider shall submit a request for prior authorization
	356	+	25 through a secure electronic transmission or an application
	357	+	26 programming interface. A health plan utilization review entity shall
	358	+	27 provide for:
	359	+	28 (1) a secure electronic transmission or an application
	360	+	29 programming interface; and
	361	+	30 (2) acknowledgment of receipt, by use of a transaction number or
	362	+	31 another reference code;
	363	+	32 of a request for prior authorization and any supporting information.
	364	+	33 (c) Subsection (b) does not apply and a health plan utilization
	365	+	34 review entity that requires prior authorization shall accept a request for
	366	+	35 prior authorization that is not submitted through a secure electronic
	367	+	36 transmission or an application programming interface if a covered
	368	+	37 individual's health care provider and the health plan utilization review
	369	+	38 entity have entered into an agreement under which the health plan
	370	+	39 utilization review entity agrees to process prior authorization requests
	371	+	40 that are not submitted through a secure electronic transmission or an
	372	+	41 application programming interface because:
	373	+	42 (1) a secure electronic transmission or an application
	374	+	ES 480—LS 7146/DI 141 9
	375	+	1 programming interface of prior authorization requests would
	376	+	2 cause financial hardship for the health care provider;
	377	+	3 (2) the area in which the health care provider is located lacks
	378	+	4 sufficient Internet access; or
	379	+	5 (3) the health care provider has an insufficient number of covered
	380	+	6 individuals as patients or customers, as determined by the
	381	+	7 commissioner, to warrant the financial expense that compliance
	382	+	8 with subsection (b) would require.
	383	+	9 (d) If a covered individual's health care provider is described in
	384	+	10 subsection (c), the health plan utilization review entity shall accept
	385	+	11 from the health care provider a request for prior authorization as
	386	+	12 follows:
	387	+	13 (1) The prior authorization request must be made on the
	388	+	14 standardized prior authorization form established by the
	389	+	15 department under section 16 of this chapter.
	390	+	16 (2) The health plan utilization review entity shall provide for a
	391	+	17 secure electronic transmission or an application programming
	392	+	18 interface and acknowledgement acknowledgment of receipt of
	393	+	19 the standardized prior authorization form and any supporting
	394	+	20 information for the prior authorization by use of a transaction
	395	+	21 number or another reference code.
	396	+	22 SECTION 20. IC 27-1-37.5-11 IS REPEALED [EFFECTIVE JULY
	397	+	23 1, 2025]. Sec. 11. (a) This section applies to a prior authorization
	398	+	24 request delivered to a health plan after December 31, 2019.
	399	+	25 (b) A health plan shall respond to a request delivered under section
	400	+	26 10 of this chapter as follows:
	401	+	27 (1) If the request is delivered under section 10(b) of this chapter,
	402	+	28 the health plan shall immediately send to the requesting health
	403	+	29 care provider an electronic receipt for the request.
	404	+	30 (2) If the request is for an urgent care situation, the health plan
	405	+	31 shall respond with a prior authorization determination not more
	406	+	32 than forty-eight (48) hours after receiving the request.
	407	+	33 (3) If the request is for a nonurgent care situation, the health plan
	408	+	34 shall respond with a prior authorization determination not more
	409	+	35 than five (5) business days after receiving the request.
	410	+	36 (c) If a request delivered under section 10 of this chapter is
	411	+	37 incomplete:
	412	+	38 (1) the health plan shall respond within the period required by
	413	+	39 subsection (b) and indicate the specific additional information
	414	+	40 required to process the request;
	415	+	41 (2) if the request was delivered under section 10(b) of this
	416	+	42 chapter, upon receiving the response under subdivision (1), the
	417	+	ES 480—LS 7146/DI 141 10
	418	+	1 health care provider shall immediately send to the health plan an
	419	+	2 electronic receipt for the response made under subdivision (1);
	420	+	3 and
	421	+	4 (3) if the request is for an urgent care situation, the health care
	422	+	5 provider shall respond to the request for additional information
	423	+	6 not more than forty-eight (48) hours after the health care provider
	424	+	7 receives the response under subdivision (1).
	425	+	8 (d) If a request delivered under section 10 of this chapter is denied,
	426	+	9 the health plan shall respond within the period required by subsection
	427	+	10 (b) and indicate the specific reason for the denial in clear and easy to
	428	+	11 understand language.
	429	+	12 SECTION 21. IC 27-1-37.5-12, AS ADDED BY P.L.77-2018,
	430	+	13 SECTION 2, IS AMENDED TO READ AS FOLLOWS [EFFECTIVE
	431	+	14 JULY 1, 2025]: Sec. 12. (a) This section applies to a claim for a health
	432	+	15 care service rendered by a participating health care provider:
	433	+	16 (1) for which:
	434	+	17 (A) prior authorization is requested after December 31, 2019;
	435	+	18 June 30, 2025; and
	436	+	19 (B) a health plan utilization review entity gives prior
	437	+	20 authorization; and
	438	+	21 (2) that is rendered in accordance with
	439	+	22 (A) the prior authorization. and
	440	+	23 (B) all terms and conditions of the participating provider's
	441	+	24 agreement or contract with the health plan.
	442	+	25 (b) The health plan utilization review entity shall not deny the
	443	+	26 claim described in subsection (a) unless:
	444	+	27 (1) the:
	445	+	28 (A) request for prior authorization; or
	446	+	29 (B) claim;
	447	+	30 contains fraudulent or materially incorrect information; or
	448	+	31 (1) the health care provider knowingly and materially
	449	+	32 misrepresented the health care service in the prior
	450	+	33 authorization request with the specific intent to deceive and
	451	+	34 obtain an unlawful payment from the utilization review
	452	+	35 entity;
	453	+	36 (2) the health care service was no longer a covered benefit on
	454	+	37 the date the health care service was provided;
	455	+	38 (3) the health care provider was no longer contracted with the
	456	+	39 patient's health plan on the date the health care service was
	457	+	40 provided;
	458	+	41 (4) the health care provider failed to meet the utilization
	459	+	42 review entity's timely filing requirements;
	460	+	ES 480—LS 7146/DI 141 11
	461	+	1 (5) the utilization review entity does not have liability for the
	462	+	2 claim; or
	463	+	3 (2) (6) the covered individual is patient was not covered under
	464	+	4 the health plan on the date on which the health care service is was
	465	+	5 rendered.
	466	+	6 (c) If:
	467	+	7 (1) the claim described in subsection (a) contains an unintentional
	468	+	8 and inaccurate inconsistency with the request for prior
	469	+	9 authorization; and
	470	+	10 (2) the inconsistency results in denial of the claim;
	471	+	11 the health care provider may resubmit the claim with accurate,
	472	+	12 corrected information.
	473	+	13 SECTION 22. IC 27-1-37.5-13, AS ADDED BY P.L.77-2018,
	474	+	14 SECTION 2, IS AMENDED TO READ AS FOLLOWS [EFFECTIVE
	475	+	15 JULY 1, 2025]: Sec. 13. (a) This section applies to a claim filed after
	476	+	16 December 31, 2018, June 30, 2025, for a medically necessary health
	477	+	17 care service rendered by a participating health care provider, the
	478	+	18 necessity of which:
	479	+	19 (1) is not anticipated at the time prior authorization is obtained for
	480	+	20 of scheduling another health care service that:
	481	+	21 (A) was authorized by the utilization review entity; or
	482	+	22 (B) is not subject to a prior authorization requirement; and
	483	+	23 (2) is determined at the time the other health care service is
	484	+	24 rendered.
	485	+	25 (b) A utilization review entity may not:
	486	+	26 (1) require retrospective review of; or
	487	+	27 (2) deny a claim based solely on lack of prior authorization
	488	+	28 for;
	489	+	29 an unanticipated health care service described in subsection (a).
	490	+	30 (c) A health care provider that renders an unanticipated health
	491	+	31 care service described in subsection (a) shall submit to the
	492	+	32 utilization review entity documentation explaining why the
	493	+	33 unanticipated health care service was medically necessary.
	494	+	34 (b) The health plan shall not deny a claim described in subsection
	495	+	35 (a) based solely on lack of prior authorization for the unanticipated
	496	+	36 health care service.
	497	+	37 (c) The health plan:
	498	+	38 (1) shall not deny payment for a health care service that is
	499	+	39 rendered in accordance with:
	500	+	40 (A) a prior authorization; and
	501	+	41 (B) all terms and conditions of the participating provider's
	502	+	42 agreement or contract with the health plan; and
	503	+	ES 480—LS 7146/DI 141 12
	504	+	1 (2) may:
	505	+	2 (A) require retrospective review of; and
	506	+	3 (B) withhold payment for;
	507	+	4 an unanticipated health care service described in subsection (a).
	508	+	5 SECTION 23. IC 27-1-37.5-13.7 IS ADDED TO THE INDIANA
	509	+	6 CODE AS A NEW SECTION TO READ AS FOLLOWS
	510	+	7 [EFFECTIVE JULY 1, 2025]: Sec. 13.7. (a) This section does not
	511	+	8 apply to the following:
	512	+	9 (1) A state employee health plan (as defined in
	513	+	10 IC 5-10-8-6.7(a)).
	514	+	11 (2) The Medicaid program.
	515	+	12 (b) A utilization review entity may not require prior
	516	+	13 authorization for the first twelve (12):
	517	+	14 (1) physical therapy; or
	518	+	15 (2) chiropractic;
	519	+	16 visits of each new episode of care.
	520	+	17 SECTION 24. IC 27-1-37.5-14, AS ADDED BY P.L.77-2018,
	521	+	18 SECTION 2, IS AMENDED TO READ AS FOLLOWS [EFFECTIVE
	522	+	19 JULY 1, 2025]: Sec. 14. A provision that:
	523	+	20 (1) is contained in a policy or contract that is entered into,
	524	+	21 amended, or renewed after June 30, 2018; 2025; and
	525	+	22 (2) contradicts this chapter;
	526	+	23 is void.
	527	+	24 SECTION 25. IC 27-1-37.5-15, AS ADDED BY P.L.77-2018,
	528	+	25 SECTION 2, IS AMENDED TO READ AS FOLLOWS [EFFECTIVE
	529	+	26 JULY 1, 2025]: Sec. 15. A violation of this chapter by a health plan
	530	+	27 utilization review entity is an unfair or deceptive act or practice in the
	531	+	28 business of insurance under IC 27-4-1-4.
	532	+	29 SECTION 26. IC 27-1-37.5-16, AS AMENDED BY P.L.265-2019,
	533	+	30 SECTION 4, IS AMENDED TO READ AS FOLLOWS [EFFECTIVE
	534	+	31 JULY 1, 2025]: Sec. 16. (a) Except as provided in subsection (b), the
	535	+	32 department shall establish, post, and maintain on the department's
	536	+	33 Internet web site website a standardized prior authorization form for
	537	+	34 use by health care providers and health plans utilization review
	538	+	35 entities for purposes of any notice or authorization required by a health
	539	+	36 plan utilization review entity with respect to payment for a health care
	540	+	37 service rendered to a covered individual.
	541	+	38 (b) After December 31, 2020, a Medicaid managed care
	542	+	39 organization (as defined in IC 12-7-2-126.9) shall use a standardized
	543	+	40 prior authorization form prescribed by the office of the secretary of
	544	+	41 family and social services.
	545	+	42 SECTION 27. IC 27-1-37.5-17, AS ADDED BY P.L.190-2023,
	546	+	ES 480—LS 7146/DI 141 13
	547	+	1 SECTION 18, IS AMENDED TO READ AS FOLLOWS [EFFECTIVE
	548	+	2 JULY 1, 2025]: Sec. 17. (a) As used in this section, "necessary
	549	+	3 information" includes the results of any face-to-face clinical evaluation,
	550	+	4 second opinion, or other clinical information that is directly applicable
	551	+	5 to the requested health care service that may be required.
	552	+	6 (b) If a health plan utilization review entity makes an adverse
	553	+	7 determination on a prior authorization request by a covered individual's
	554	+	8 health care provider, the health plan utilization review entity must
	555	+	9 offer the covered individual's health care provider the option to request
	556	+	10 a peer to peer review by a clinical peer concerning the adverse
	557	+	11 determination.
	558	+	12 (c) A covered individual's health care provider may request a peer
	559	+	13 to peer review by a clinical peer either in writing or electronically.
	560	+	14 (d) If a peer to peer review by a clinical peer is requested under this
	561	+	15 section:
	562	+	16 (1) the health plan's utilization review entity's clinical peer and
	563	+	17 the covered individual's health care provider or the health care
	564	+	18 provider's designee shall make every effort to provide the peer to
	565	+	19 peer review not later than seven (7) business days forty-eight
	566	+	20 (48) hours (excluding weekends and state and federal legal
	567	+	21 holidays) from the date of receipt by the health plan after the
	568	+	22 utilization review entity receives of the request by the covered
	569	+	23 individual's health care provider for a peer to peer review if the
	570	+	24 health plan utilization review entity has received the necessary
	571	+	25 information for the peer to peer review; and
	572	+	26 (2) the health plan utilization review entity must have the peer
	573	+	27 to peer review conducted between the clinical peer and the
	574	+	28 covered individual's health care provider or the provider's
	575	+	29 designee.
	576	+	30 SECTION 28. IC 27-1-37.5-19 IS ADDED TO THE INDIANA
	577	+	31 CODE AS A NEW SECTION TO READ AS FOLLOWS
	578	+	32 [EFFECTIVE JULY 1, 2025]: Sec. 19. (a) A utilization review entity
	579	+	33 shall make any current prior authorization requirements and
	580	+	34 restrictions, including written clinical criteria, readily accessible on
	581	+	35 the utilization review entity's website to covered individuals, health
	582	+	36 care providers, and the general public. The prior authorization
	583	+	37 requirements and restrictions must be described in detail and in
	584	+	38 easily understandable language.
	585	+	39 (b) A utilization review entity may not implement a new prior
	586	+	40 authorization requirement or restriction or amend an existing
	587	+	41 requirement or restriction unless:
	588	+	42 (1) the utilization review entity's website has been updated to
	589	+	ES 480—LS 7146/DI 141 14
	590	+	1 reflect the new or amended requirement or restriction; and
	591	+	2 (2) the utilization review entity provides written notice to
	592	+	3 covered individuals and health care providers at least sixty
	593	+	4 (60) days before the requirement or restriction is
	594	+	5 implemented.
	595	+	6 (c) A utilization review entity shall make statistics available
	596	+	7 regarding prior authorization approvals and denials on the
	597	+	8 utilization review entity's website in a readily accessible format,
	598	+	9 including statistics for the following categories:
	599	+	10 (1) Health care provider specialty.
	600	+	11 (2) Medication or diagnostic test or procedure.
	601	+	12 (3) Indication offered.
	602	+	13 (4) Reason for denial.
	603	+	14 (5) If a decision was appealed.
	604	+	15 (6) If a decision was approved or denied on appeal.
	605	+	16 (7) The time between submission and the response.
	606	+	17 (d) Not later than December 31 of each year, a utilization review
	607	+	18 entity shall:
	608	+	19 (1) prepare a report of the statistics compiled under
	609	+	20 subsection (c); and
	610	+	21 (2) submit the report to the department.
	611	+	22 SECTION 29. IC 27-1-37.5-20 IS ADDED TO THE INDIANA
	612	+	23 CODE AS A NEW SECTION TO READ AS FOLLOWS
	613	+	24 [EFFECTIVE JULY 1, 2025]: Sec. 20. (a) A utilization review entity
	614	+	25 must ensure that:
	615	+	26 (1) all:
	616	+	27 (A) adverse determinations based on medical necessity are
	617	+	28 made; and
	618	+	29 (B) appeals are reviewed and decided;
	619	+	30 by a clinical peer; and
	620	+	31 (2) when making an adverse determination based on medical
	621	+	32 necessity or reviewing and deciding an appeal, the clinical
	622	+	33 peer is under the clinical direction of a medical director of the
	623	+	34 utilization review entity who is:
	624	+	35 (A) responsible for the provision of health care services
	625	+	36 provided to covered individuals; and
	626	+	37 (B) a physician licensed in Indiana under IC 25-22.5.
	627	+	38 (b) An appeal may not be reviewed or decided by a clinical peer
	628	+	39 who:
	629	+	40 (1) has a financial interest in the outcome of the appeal; or
	630	+	41 (2) was involved in making the adverse determination that is
	631	+	42 the subject of the appeal.
	632	+	ES 480—LS 7146/DI 141 15
	633	+	1 SECTION 30. IC 27-1-37.5-21 IS ADDED TO THE INDIANA
	634	+	2 CODE AS A NEW SECTION TO READ AS FOLLOWS
	635	+	3 [EFFECTIVE JULY 1, 2025]: Sec. 21. A clinical peer who:
	636	+	4 (1) makes an adverse determination; or
	637	+	5 (2) reviews and decides an appeal;
	638	+	6 owes a duty to the covered individual to exercise the applicable
	639	+	7 standard of care.
	640	+	8 SECTION 31. IC 27-1-37.5-23 IS ADDED TO THE INDIANA
	641	+	9 CODE AS A NEW SECTION TO READ AS FOLLOWS
	642	+	10 [EFFECTIVE JULY 1, 2025]: Sec. 23. (a) The time frames set forth
	643	+	11 in this section do not include weekends and state and federal legal
	644	+	12 holidays.
	645	+	13 (b) A utilization review entity shall respond to a request for
	646	+	14 prior authorization as follows:
	647	+	15 (1) If the request for prior authorization is for an urgent
	648	+	16 health care service, the utilization review entity shall respond
	649	+	17 with an authorization or adverse determination not later than
	650	+	18 twenty-four (24) hours after receiving the request.
	651	+	19 (2) If the request for prior authorization is:
	652	+	20 (A) for a health care service other than the health care
	653	+	21 services described in subdivision (1); or
	654	+	22 (B) for a prescription drug;
	655	+	23 the utilization review entity shall respond with an
	656	+	24 authorization or adverse determination not later than
	657	+	25 forty-eight (48) hours after receiving the request.
	658	+	26 (c) If a utilization review entity issues an adverse determination
	659	+	27 in a response under subsection (b), the response must include the
	660	+	28 following information:
	661	+	29 (1) Specific reasons for the adverse determination.
	662	+	30 (2) Suggested alternatives to the requested health care service.
	663	+	31 (d) A health care provider shall respond not later than
	664	+	32 forty-eight (48) hours after receiving an adverse determination
	665	+	33 under subsection (b) if the health care provider:
	666	+	34 (1) needs to correct a typographical, clerical, or spelling
	667	+	35 error; or
	668	+	36 (2) accepts an alternative suggested by the utilization review
	669	+	37 entity.
	670	+	38 (e) Not later than forty-eight (48) hours after receiving a health
	671	+	39 care provider's response under subsection (d), the utilization
	672	+	40 review entity shall:
	673	+	41 (1) render a prior authorization or adverse determination
	674	+	42 based on the information provided in the health care
	675	+	ES 480—LS 7146/DI 141 16
	676	+	1 provider's response; and
	677	+	2 (2) notify the health care provider of the authorization or
	678	+	3 adverse determination.
	679	+	4 (f) A health care provider may appeal an adverse determination
	680	+	5 received under subsection (b) or (e). The health care provider shall
	681	+	6 notify the utilization review entity of an appeal not later than
	682	+	7 forty-eight (48) hours after receiving notice of the adverse
	683	+	8 determination.
	684	+	9 (g) A utilization review entity shall respond to an appeal under
	685	+	10 subsection (f) not later than forty-eight (48) hours after receiving
	686	+	11 notice of the appeal.
	687	+	12 SECTION 32. IC 27-1-37.5-24 IS ADDED TO THE INDIANA
	688	+	13 CODE AS A NEW SECTION TO READ AS FOLLOWS
	689	+	14 [EFFECTIVE JULY 1, 2025]: Sec. 24. (a) A utilization review entity
	690	+	15 shall allow a covered individual and a covered individual's health
	691	+	16 care provider at least twenty-four (24) hours (excluding weekends
	692	+	17 and state and federal legal holidays) after an emergency admission
	693	+	18 or provision of emergency health care services for the covered
	694	+	19 individual or health care provider to notify the utilization review
	695	+	20 entity of the emergency admission or provision of the emergency
	696	+	21 health care service.
	697	+	22 (b) A utilization review entity shall cover emergency health care
	698	+	23 services necessary to screen and stabilize a covered individual. If
	699	+	24 a health care provider certifies in writing to a utilization review
	700	+	25 entity not later than seventy-two (72) hours (excluding weekends
	701	+	26 and state and federal legal holidays) after a covered individual's
	702	+	27 emergency admission that the covered individual's condition
	703	+	28 required the emergency health care service, the certification will
	704	+	29 create a presumption that the emergency health care service was
	705	+	30 medically necessary. The presumption may be rebutted only if the
	706	+	31 utilization review entity can establish, with clear and convincing
	707	+	32 evidence, that the emergency health care service was not medically
	708	+	33 necessary.
	709	+	34 (c) The medical necessity of an emergency health care service
	710	+	35 may not be based on whether the service was provided by a
	711	+	36 participating or nonparticipating provider. Any restriction on the
	712	+	37 coverage of an emergency health care service provided by a
	713	+	38 nonparticipating provider may not be greater than the restriction
	714	+	39 that applies when the service is provided by a participating
	715	+	40 provider.
	716	+	41 SECTION 33. IC 27-1-37.5-25 IS ADDED TO THE INDIANA
	717	+	42 CODE AS A NEW SECTION TO READ AS FOLLOWS
	718	+	ES 480—LS 7146/DI 141 17
	719	+	1 [EFFECTIVE JULY 1, 2025]: Sec. 25. A utilization review entity
	720	+	2 may not revoke, limit, condition, or restrict an authorization if the
	721	+	3 health care provider begins providing the health care service not
	722	+	4 later than forty-five (45) days (excluding weekends and state and
	723	+	5 federal legal holidays) after the date the health care provider
	724	+	6 received the authorization.
	725	+	7 SECTION 34. IC 27-1-37.5-26 IS ADDED TO THE INDIANA
	726	+	8 CODE AS A NEW SECTION TO READ AS FOLLOWS
	727	+	9 [EFFECTIVE JULY 1, 2025]: Sec. 26. (a) The authorization periods
	728	+	10 in this section do not apply if:
	729	+	11 (1) the health care provider has not begun providing the
	730	+	12 health care service within forty-five (45) days (excluding
	731	+	13 weekends and state and federal legal holidays) after receiving
	732	+	14 the authorization as set forth in section 25 of this chapter; and
	733	+	15 (2) the utilization review entity revokes, limits, conditions, or
	734	+	16 restricts the authorization.
	735	+	17 (b) An authorization for a health care service shall be valid for
	736	+	18 at least one (1) year after the date the health care provider receives
	737	+	19 the authorization.
	738	+	20 (c) The authorization period under subsection (b) is effective
	739	+	21 regardless of any changes in dosage for a prescription drug
	740	+	22 prescribed by the health care provider.
	741	+	23 SECTION 35. IC 27-1-37.5-27 IS ADDED TO THE INDIANA
	742	+	24 CODE AS A NEW SECTION TO READ AS FOLLOWS
	743	+	25 [EFFECTIVE JULY 1, 2025]: Sec. 27. (a) A utilization review entity
	744	+	26 shall honor an authorization that was granted to a covered
	745	+	27 individual by a previous utilization review entity for at least the
	746	+	28 initial ninety (90) days of the covered individual's coverage under
	747	+	29 a new health plan if:
	748	+	30 (1) the utilization review entity receives information
	749	+	31 documenting the authorization from the covered individual or
	750	+	32 the covered individual's health care provider; and
	751	+	33 (2) the authorization is for a health care service that is
	752	+	34 covered under the new health plan.
	753	+	35 (b) During the time period described in subsection (a), a
	754	+	36 utilization review entity may perform its own review of the prior
	755	+	37 authorization request.
	756	+	38 (c) If there is a change in:
	757	+	39 (1) coverage of; or
	758	+	40 (2) approval criteria for;
	759	+	41 a previously authorized health care service, the change in coverage
	760	+	42 or approval criteria may not affect a covered individual who
	761	+	ES 480—LS 7146/DI 141 18
	762	+	1 received authorization before the effective date of the change for
	763	+	2 the remainder of the plan year.
	764	+	3 (d) A utilization review entity shall continue to honor an
	765	+	4 authorization that the utilization review entity granted to a covered
	766	+	5 individual when the covered individual changes products under the
	767	+	6 same health insurance company.
	768	+	7 SECTION 36. IC 27-1-37.5-28 IS ADDED TO THE INDIANA
	769	+	8 CODE AS A NEW SECTION TO READ AS FOLLOWS
	770	+	9 [EFFECTIVE JULY 1, 2025]: Sec. 28. If a utilization review entity
	771	+	10 fails to comply with the deadlines or other requirements under this
	772	+	11 chapter, the health care service subject to prior authorization shall
	773	+	12 be automatically deemed authorized by the utilization review
	774	+	13 entity.
	775	+	14 SECTION 37. IC 27-8-5.7-12 IS ADDED TO THE INDIANA
	776	+	15 CODE AS A NEW SECTION TO READ AS FOLLOWS
	777	+	16 [EFFECTIVE JULY 1, 2025]: Sec. 12. (a) This section applies to a
	778	+	17 policy of accident and sickness insurance that is issued, delivered,
	779	+	18 amended, or renewed after June 30, 2025.
	780	+	19 (b) An insurer may not deny a claim for reimbursement for a
	781	+	20 covered service or item provided to an insured on the sole basis
	782	+	21 that the referring provider is an out of network provider.
	783	+	22 SECTION 38. IC 27-13-36.2-10 IS ADDED TO THE INDIANA
	784	+	23 CODE AS A NEW SECTION TO READ AS FOLLOWS
	785	+	24 [EFFECTIVE JULY 1, 2025]: Sec. 10. (a) This section applies to an
	786	+	25 individual contract and a group contract that is entered into,
	787	+	26 delivered, amended, or renewed after June 30, 2025.
	788	+	27 (b) A health maintenance organization may not deny a claim for
	789	+	28 reimbursement for a covered service or item provided to an
	790	+	29 enrollee on the sole basis that the referring provider is an out of
	791	+	30 network provider.
	792	+	ES 480—LS 7146/DI 141 19
	793	+	COMMITTEE REPORT
	794	+	Mr. President: The Senate Committee on Health and Provider
	795	+	Services, to which was referred Senate Bill No. 480, has had the same
	796	+	under consideration and begs leave to report the same back to the
	797	+	Senate with the recommendation that said bill DO PASS and be
	798	+	reassigned to the Senate Committee on Appropriations.
	799	+	(Reference is to SB 480 as introduced.)
	800	+	CHARBONNEAU, Chairperson
	801	+	Committee Vote: Yeas 12, Nays 0
	802	+	_____
	803	+	COMMITTEE REPORT
	804	+	Mr. President: The Senate Committee on Appropriations, to which
	805	+	was referred Senate Bill No. 480, has had the same under consideration
	806	+	and begs leave to report the same back to the Senate with the
	807	+	recommendation that said bill be AMENDED as follows:
	808	+	Page 4, delete lines 38 through 42.
	809	+	Page 5, delete lines 1 through 6.
	810	+	Page 5, delete lines 23 through 42.
	811	+	Page 6, delete lines 1 through 3.
	812	+	Page 13, delete lines 1 through 33.
	813	+	Page 14, line 30, delete "physician." and insert "practitioner of the
	814	+	same license type.".
	815	+	Page 14, line 31, delete "physician" and insert "practitioner of the
	816	+	same license type".
	817	+	Page 14, line 33, delete "to".
	818	+	Page 14, line 34, delete "practice medicine".
	819	+	Page 14, line 35, delete "physician" and insert "practitioner of the
	820	+	same license type".
	821	+	Page 15, delete lines 7 through 22.
	822	+	Page 16, delete lines 27 through 42.
	823	+	Page 17, line 1, delete "(3)" and insert "(1)".
	824	+	Page 17, line 5, delete "(4)" and insert "(2)".
	825	+	Page 17, line 7, delete "subdivisions (2) and (3);" and insert
	826	+	"subdivision (1); or".
	827	+	Page 17, line 8, delete "drug that:" and insert "drug;".
	828	+	Page 17, delete lines 9 through 14.
	829	+	Page 17, line 41, delete "twenty-four (24) hours" and insert
	830	+	ES 480—LS 7146/DI 141 20
	831	+	"forty-eight (48) hours".
	832	+	Page 18, line 2, delete "twenty-four (24) hours" and insert
	833	+	"forty-eight (48) hours".
	834	+	Page 20, delete lines 9 through 34.
	835	+	Renumber all SECTIONS consecutively.
	836	+	and when so amended that said bill do pass.
	837	+	(Reference is to SB 480 as introduced.)
	838	+	MISHLER, Chairperson
	839	+	Committee Vote: Yeas 11, Nays 0.
	840	+	_____
	841	+	COMMITTEE REPORT
	842	+	Mr. Speaker: Your Committee on Insurance, to which was referred
	843	+	Senate Bill 480, has had the same under consideration and begs leave
	844	+	to report the same back to the House with the recommendation that said
	845	+	bill be amended as follows:
	846	+	Page 2, delete lines 32 through 41, begin a new paragraph and
	847	+	insert:
	848	+	"SECTION 5. IC 27-1-37.5-1.7, AS ADDED BY P.L.190-2023,
64	849		SECTION 15, IS AMENDED TO READ AS FOLLOWS [EFFECTIVE
65	850		JULY 1, 2025]: Sec. 1.7. As used in this chapter, "clinical peer" means
66	851		a practitioner or other health care provider who either: the following:
67	852		(1) Except as provided in subdivision (3), for a review of a
68	853		request from a physician, a physician who:
69	854		(A) holds a current and valid license in any United States
70	855		jurisdiction; under IC 25-22.5, (2) has been granted
71	856		reciprocity in the state, under IC 25-1-21, if reciprocity exists,
72	857		or (3) holds a license that is part of a compact in which the
73	858		state Indiana has entered;
74	859		(B) is certified in the same specialty as the physician under
75	860		review, as recognized by:
76	861		(i) the American Board of Medical Specialties; or
77	862		(ii) the American Osteopathic Association; and
78	863		(C) if the review specifically concerns subspecialty care, is
79		-	SEA 480 — Concur 3
80	864		certified in the same subspecialty as the physician under
81	865		review, as recognized by:
82	866		(i) the American Board of Medical Specialties; or
83	867		(ii) the American Osteopathic Association.
	868	+	ES 480—LS 7146/DI 141 21
84	869		(2) For a review of a request from an advanced practice
85	870		registered nurse, an advanced practice registered nurse who:
86	871		(A) holds a current and valid license under IC 25-23-1 or
87	872		has been granted reciprocity under IC 25-1-21, if
88	873		reciprocity exists, or holds a license that is part of a
89	874		compact in which Indiana has entered; and
90	875		(B) holds equivalent or similar:
91	876		(i) population focus; and
92	877		(ii) role specialty;
93	878		as the advanced practice registered nurse who is subject to
94	879		the review.
95	880		(3) For a review of a request from a primary care physician
96	881		(as defined in IC 25-22.5-5.5-1.5), a physician who:
97	882		(A) holds a current and valid license under IC 25-22.5, has
98	883		been granted reciprocity under IC 25-1-21, if reciprocity
99	884		exists, or holds a license that is part of a compact in which
100	885		Indiana has entered;
101	886		(B) is certified in the same general practice of medicine
102	887		under review, as recognized by:
103	888		(i) the American Board of Medical Specialties;
104	889		(ii) the American Board of Pediatrics; or
105	890		(iii) the American Osteopathic Association; and
106	891		(C) has been actively engaged in general practice for at
107	892		least three (3) years.
108	893		(4) For a review of a request from a practitioner or health
109	894		care provider other than those specified in subdivisions (1)
110	895		through (3), a practitioner or health care provider who:
111	896		(A) holds a current and valid license in Indiana;
112	897		(B) has been granted reciprocity in Indiana, if reciprocity
113	898		exists; or
114	899		(C) holds a license that is part of a compact in which
115		-	Indiana has entered.
116		-	SECTION 6. IC 27-1-37.5-1.8 IS ADDED TO THE INDIANA
117		-	CODE AS A NEW SECTION TO READ AS FOLLOWS
118		-	[EFFECTIVE JULY 1, 2025]: Sec. 1.8. As used in this chapter,
119		-	"clinical criteria" means:
120		-	(1) written policies;
121		-	(2) written screen procedures;
122		-	SEA 480 — Concur 4
123		-	(3) drug formularies or lists of covered drugs;
124		-	(4) determination rules;
125		-	(5) determination abstracts;
126		-	(6) clinical protocols;
127		-	(7) practice guidelines;
128		-	(8) medical protocols; and
129		-	(9) any other criteria or rationale;
130		-	used by the utilization review entity to determine the medical
131		-	necessity of a health care service.
132		-	SECTION 7. IC 27-1-37.5-1.9 IS ADDED TO THE INDIANA
133		-	CODE AS A NEW SECTION TO READ AS FOLLOWS
134		-	[EFFECTIVE JULY 1, 2025]: Sec. 1.9. (a) As used in this chapter,
135		-	"cosmetic surgery" means any procedure that:
136		-	(1) is directed at improving the patient's appearance; and
137		-	(2) does not meaningfully:
138		-	(A) promote the proper function of the body; or
139		-	(B) prevent or treat illness or disease.
140		-	(b) The term does not include the following:
141		-	(1) A procedure that is necessary to ameliorate a deformity
142		-	arising from or directly related to a:
143		-	(A) congenital abnormality;
144		-	(B) personal injury resulting from an accident or trauma;
145		-	or
146		-	(C) disfiguring disease.
147		-	(2) A procedure related to the treatment of breast cancer.
148		-	SECTION 8. IC 27-1-37.5-2, AS ADDED BY P.L.77-2018,
149		-	SECTION 2, IS AMENDED TO READ AS FOLLOWS [EFFECTIVE
150		-	JULY 1, 2025]: Sec. 2. As used in this chapter, "covered individual"
151		-	means an individual who is covered under a health plan. The term
152		-	includes a covered individual's legally authorized representative.
153		-	SECTION 9. IC 27-1-37.5-3.7 IS ADDED TO THE INDIANA
154		-	CODE AS A NEW SECTION TO READ AS FOLLOWS
155		-	[EFFECTIVE JULY 1, 2025]: Sec. 3.7. As used in this chapter,
156		-	"emergency health care service" means a health care service that
157		-	is provided in an emergency facility after the sudden onset of a
158		-	medical condition that manifests itself by symptoms of sufficient
159		-	severity, including severe pain, that the absence of immediate
160		-	medical attention could reasonably be expected by a prudent
161		-	layperson who possesses average knowledge of health and medicine
162		-	to:
163		-	(1) place an individual's health in serious jeopardy;
164		-	(2) result in serious impairment to the individual's bodily
165		-	SEA 480 — Concur 5
166		-	function; or
167		-	(3) result in serious dysfunction of any bodily organ or part of
168		-	the individual.
169		-	SECTION 10. IC 27-1-37.5-3.8 IS ADDED TO THE INDIANA
170		-	CODE AS A NEW SECTION TO READ AS FOLLOWS
171		-	[EFFECTIVE JULY 1, 2025]: Sec. 3.8. As used in this chapter,
172		-	"episode of care" means the medical care ordered to be provided
173		-	for a specific medical procedure, condition, or illness.
174		-	SECTION 11. IC 27-1-37.5-3.9 IS ADDED TO THE INDIANA
175		-	CODE AS A NEW SECTION TO READ AS FOLLOWS
176		-	[EFFECTIVE JULY 1, 2025]: Sec. 3.9. (a) As used in this chapter,
177		-	except as provided in subsection (b), "health care provider" means
178		-	an individual who holds a license issued by a board described in
179		-	IC 25-0.5-11.
180		-	(b) The term does not include the following:
181		-	(1) A dentist licensed under IC 25-14.
182		-	(2) An optometrist licensed under IC 25-24.
183		-	(3) A veterinarian licensed under IC 25-38.1.
184		-	SECTION 12. IC 27-1-37.5-4, AS ADDED BY P.L.77-2018,
185		-	SECTION 2, IS AMENDED TO READ AS FOLLOWS [EFFECTIVE
186		-	JULY 1, 2025]: Sec. 4. (a) As used in this chapter, "health care service"
187		-	means a health care related service or product rendered or sold
188		-	procedure, treatment, or service provided by:
189		-	(1) a health care facility (as defined in IC 16-18-2-161(a));
190		-	(2) an ambulatory outpatient surgical center (as defined in
191		-	IC 16-18-2-14); or
192		-	(3) a health care provider within the scope of practice of the
193		-	health care provider's license or legal authorization.
194		-	including hospital, medical, surgical, mental health, and substance
195		-	abuse services or products. The term includes the provision of
196		-	pharmaceutical products or services or durable medical
197		-	equipment.
198		-	(b) The term does not include the following:
199		-	(1) Dental services.
200		-	(2) Vision services.
201		-	(3) Long term rehabilitation treatment. Cosmetic surgery.
202		-	(4) Pharmaceutical services or products.
203		-	SECTION 13. IC 27-1-37.5-5.4 IS ADDED TO THE INDIANA
204		-	CODE AS A NEW SECTION TO READ AS FOLLOWS
205		-	[EFFECTIVE JULY 1, 2025]: Sec. 5.4. As used in this chapter,
206		-	"medically necessary" means a health care service that a prudent
207		-	health care provider would provide to a patient for the purpose of
208		-	SEA 480 — Concur 6
209		-	preventing, diagnosing, or treating an illness, injury, disease, or
210		-	symptoms in a manner that is:
211		-	(1) in accordance with generally accepted standards of
212		-	medical practice;
213		-	(2) clinically appropriate in terms of type, frequency, extent,
214		-	site, and duration; and
215		-	(3) not primarily for:
216		-	(A) the economic benefit of the health plan or purchaser;
217		-	or
218		-	(B) the convenience of the health plan, patient, treating
219		-	physician, or other health care provider.
220		-	SECTION 14. IC 27-1-37.5-7, AS ADDED BY P.L.77-2018,
221		-	SECTION 2, IS AMENDED TO READ AS FOLLOWS [EFFECTIVE
222		-	JULY 1, 2025]: Sec. 7. As used in this chapter, "prior authorization"
223		-	means a practice implemented by a health plan through which coverage
224		-	of a health care service is dependent on the covered individual or
225		-	health care provider obtaining approval from the health plan before the
226		-	health care service is rendered. The term includes prospective or
227		-	utilization review procedures conducted before a health care service is
228		-	rendered. the process by which a utilization review entity
229		-	determines the medical necessity of an otherwise covered health
230		-	care service before the health care service is rendered. The term
231		-	includes a utilization review entity's requirement that a covered
232		-	individual or health care provider notify the utilization review
233		-	entity prior to providing a health care service.
234		-	SECTION 15. IC 27-1-37.5-8 IS REPEALED [EFFECTIVE JULY
235		-	1, 2025]. Sec. 8. As used in this chapter, "urgent care situation" means
236		-	a situation in which a covered individual's treating physician has
237		-	determined that the covered individual's condition is likely to result in:
238		-	(1) adverse health consequences or serious jeopardy to the
239		-	covered individual's life, health, or safety; or
240		-	(2) due to the covered individual's psychological state, serious
241		-	jeopardy to the life, health, or safety of another individual;
242		-	unless treatment of the covered individual's condition for which prior
243		-	authorization is sought occurs earlier than the period generally
244		-	considered by the medical profession to be reasonable to treat routine
245		-	or non-life threatening conditions.
246		-	SECTION 16. IC 27-1-37.5-8.1 IS ADDED TO THE INDIANA
247		-	CODE AS A NEW SECTION TO READ AS FOLLOWS
248		-	[EFFECTIVE JULY 1, 2025]: Sec. 8.1. As used in this chapter,
249		-	"urgent health care service" means a health care service in which
250		-	the application of the time period for making a nonexpedited prior
251		-	SEA 480 — Concur 7
252		-	authorization, in the opinion of a physician with knowledge of the
253		-	covered individual's medical condition, could:
254		-	(1) seriously jeopardize:
255		-	(A) the life or health of the covered individual; or
256		-	(B) the covered individual's ability to regain maximum
257		-	function; or
258		-	(2) subject the covered individual to severe pain that cannot
259		-	be adequately managed without the health care service.
260		-	The term includes a mental and behavioral health care service.
261		-	SECTION 17. IC 27-1-37.5-8.3 IS ADDED TO THE INDIANA
262		-	CODE AS A NEW SECTION TO READ AS FOLLOWS
263		-	[EFFECTIVE JULY 1, 2025]: Sec. 8.3. As used in this chapter,
264		-	"utilization review entity" means an individual or entity that
265		-	performs prior authorization for one (1) or more of the following:
266		-	(1) An employer who employs a covered individual.
267		-	(2) A health plan.
268		-	(3) A preferred provider organization.
269		-	(4) Any other individual or entity that:
270		-	(A) provides;
271		-	(B) offers to provide; or
272		-	(C) administers;
273		-	hospital, outpatient, medical, prescription drug, or other
274		-	health benefits to a covered individual.
275		-	SECTION 18. IC 27-1-37.5-9 IS REPEALED [EFFECTIVE JULY
276		-	1, 2025]. Sec. 9. (a) A health plan shall make available to participating
277		-	providers on the health plan's Internet web site or portal the applicable
278		-	CPT code for the specific health care services for which prior
279		-	authorization is required.
280		-	(b) A health plan shall make available to participating providers, on
281		-	the health plan's Internet web site or portal, a list of the health plan's
282		-	prior authorization requirements, including specific information that a
283		-	provider must submit to establish a complete request for prior
284		-	authorization. This subsection does not prevent a health plan from
285		-	requiring specific additional information upon review of the request for
286		-	prior authorization.
287		-	(c) A health plan shall, not less than forty-five (45) days before the
288		-	prior authorization requirement becomes effective, disclose to a
289		-	participating provider any new prior authorization requirement.
290		-	(d) A disclosure made under subsection (c) must:
291		-	(1) be sent via electronic or United States mail and conspicuously
292		-	labeled "Notice of Changes to Prior Authorization Requirements";
293		-	and
294		-	SEA 480 — Concur 8
295		-	(2) specifically identify the location on the health plan's Internet
296		-	web site or portal of the new prior authorization requirement.
297		-	However, a health plan is considered to have met the requirements of
298		-	this subsection if the health plan conspicuously posts the information
299		-	required by this subsection, including the effective date of the new
300		-	prior authorization requirement, on the health plan's Internet web site.
301		-	(e) A participating provider shall, not more than seven (7) days after
302		-	the change is made, notify the health plan of a change in the
303		-	participating provider's electronic or United States mail address.
304		-	SECTION 19. IC 27-1-37.5-10, AS ADDED BY P.L.208-2018,
305		-	SECTION 8, IS AMENDED TO READ AS FOLLOWS [EFFECTIVE
306		-	JULY 1, 2025]: Sec. 10. (a) This section applies to a request for prior
307		-	authorization delivered to a health plan after December 31, 2019. does
308		-	not apply to prior authorization for a prescription drug.
309		-	(b) A health plan utilization review entity shall accept a request for
310		-	prior authorization delivered to the health plan utilization review
311		-	entity by a covered individual's health care provider through a secure
312		-	electronic transmission or an application programming interface. A
313		-	health care provider shall submit a request for prior authorization
314		-	through a secure electronic transmission or an application
315		-	programming interface. A health plan utilization review entity shall
316		-	provide for:
317		-	(1) a secure electronic transmission or an application
318		-	programming interface; and
319		-	(2) acknowledgment of receipt, by use of a transaction number or
320		-	another reference code;
321		-	of a request for prior authorization and any supporting information.
322		-	(c) Subsection (b) does not apply and a health plan utilization
323		-	review entity that requires prior authorization shall accept a request for
324		-	prior authorization that is not submitted through a secure electronic
325		-	transmission or an application programming interface if a covered
326		-	individual's health care provider and the health plan utilization review
327		-	entity have entered into an agreement under which the health plan
328		-	utilization review entity agrees to process prior authorization requests
329		-	that are not submitted through a secure electronic transmission or an
330		-	application programming interface because:
331		-	(1) a secure electronic transmission or an application
332		-	programming interface of prior authorization requests would
333		-	cause financial hardship for the health care provider;
334		-	(2) the area in which the health care provider is located lacks
335		-	sufficient Internet access; or
336		-	(3) the health care provider has an insufficient number of covered
337		-	SEA 480 — Concur 9
338		-	individuals as patients or customers, as determined by the
339		-	commissioner, to warrant the financial expense that compliance
340		-	with subsection (b) would require.
341		-	(d) If a covered individual's health care provider is described in
342		-	subsection (c), the health plan utilization review entity shall accept
343		-	from the health care provider a request for prior authorization as
344		-	follows:
345		-	(1) The prior authorization request must be made on the
346		-	standardized prior authorization form established by the
347		-	department under section 16 of this chapter.
348		-	(2) The health plan utilization review entity shall provide for a
349		-	secure electronic transmission or an application programming
350		-	interface and acknowledgement acknowledgment of receipt of
351		-	the standardized prior authorization form and any supporting
352		-	information for the prior authorization by use of a transaction
353		-	number or another reference code.
354		-	SECTION 20. IC 27-1-37.5-11 IS REPEALED [EFFECTIVE JULY
355		-	1, 2025]. Sec. 11. (a) This section applies to a prior authorization
356		-	request delivered to a health plan after December 31, 2019.
357		-	(b) A health plan shall respond to a request delivered under section
358		-	10 of this chapter as follows:
359		-	(1) If the request is delivered under section 10(b) of this chapter,
360		-	the health plan shall immediately send to the requesting health
361		-	care provider an electronic receipt for the request.
362		-	(2) If the request is for an urgent care situation, the health plan
363		-	shall respond with a prior authorization determination not more
364		-	than forty-eight (48) hours after receiving the request.
365		-	(3) If the request is for a nonurgent care situation, the health plan
366		-	shall respond with a prior authorization determination not more
367		-	than five (5) business days after receiving the request.
368		-	(c) If a request delivered under section 10 of this chapter is
369		-	incomplete:
370		-	(1) the health plan shall respond within the period required by
371		-	subsection (b) and indicate the specific additional information
372		-	required to process the request;
373		-	(2) if the request was delivered under section 10(b) of this
374		-	chapter, upon receiving the response under subdivision (1), the
375		-	health care provider shall immediately send to the health plan an
376		-	electronic receipt for the response made under subdivision (1);
377		-	and
378		-	(3) if the request is for an urgent care situation, the health care
379		-	provider shall respond to the request for additional information
380		-	SEA 480 — Concur 10
381		-	not more than forty-eight (48) hours after the health care provider
382		-	receives the response under subdivision (1).
383		-	(d) If a request delivered under section 10 of this chapter is denied,
384		-	the health plan shall respond within the period required by subsection
385		-	(b) and indicate the specific reason for the denial in clear and easy to
386		-	understand language.
387		-	SECTION 21. IC 27-1-37.5-12, AS ADDED BY P.L.77-2018,
388		-	SECTION 2, IS AMENDED TO READ AS FOLLOWS [EFFECTIVE
389		-	JULY 1, 2025]: Sec. 12. (a) This section applies to a claim for a health
390		-	care service rendered by a participating health care provider:
391		-	(1) for which:
392		-	(A) prior authorization is requested after December 31, 2019;
393		-	June 30, 2025; and
394		-	(B) a health plan utilization review entity gives prior
395		-	authorization; and
396		-	(2) that is rendered in accordance with
397		-	(A) the prior authorization. and
398		-	(B) all terms and conditions of the participating provider's
399		-	agreement or contract with the health plan.
400		-	(b) The health plan utilization review entity shall not deny the
401		-	claim described in subsection (a) unless:
402		-	(1) the:
403		-	(A) request for prior authorization; or
404		-	(B) claim;
405		-	contains fraudulent or materially incorrect information; or
406		-	(1) the health care provider knowingly and materially
407		-	misrepresented the health care service in the prior
408		-	authorization request with the specific intent to deceive and
409		-	obtain an unlawful payment from the utilization review
410		-	entity;
411		-	(2) the health care service was no longer a covered benefit on
412		-	the date the health care service was provided;
413		-	(3) the health care provider was no longer contracted with the
414		-	patient's health plan on the date the health care service was
415		-	provided;
416		-	(4) the health care provider failed to meet the utilization
417		-	review entity's timely filing requirements;
418		-	(5) the utilization review entity does not have liability for the
419		-	claim; or
420		-	(2) (6) the covered individual is patient was not covered under
421		-	the health plan on the date on which the health care service is was
422		-	rendered.
423		-	SEA 480 — Concur 11
424		-	(c) If:
425		-	(1) the claim described in subsection (a) contains an unintentional
426		-	and inaccurate inconsistency with the request for prior
427		-	authorization; and
428		-	(2) the inconsistency results in denial of the claim;
429		-	the health care provider may resubmit the claim with accurate,
430		-	corrected information.
431		-	SECTION 22. IC 27-1-37.5-13, AS ADDED BY P.L.77-2018,
432		-	SECTION 2, IS AMENDED TO READ AS FOLLOWS [EFFECTIVE
433		-	JULY 1, 2025]: Sec. 13. (a) This section applies to a claim filed after
434		-	December 31, 2018, June 30, 2025, for a medically necessary health
435		-	care service rendered by a participating health care provider, the
436		-	necessity of which:
437		-	(1) is not anticipated at the time prior authorization is obtained for
438		-	of scheduling another health care service that:
439		-	(A) was authorized by the utilization review entity; or
440		-	(B) is not subject to a prior authorization requirement; and
441		-	(2) is determined at the time the other health care service is
442		-	rendered.
443		-	(b) A utilization review entity may not:
444		-	(1) require retrospective review of; or
445		-	(2) deny a claim based solely on lack of prior authorization
446		-	for;
447		-	an unanticipated health care service described in subsection (a).
448		-	(c) A health care provider that renders an unanticipated health
	900	+	Indiana has entered.".
	901	+	Page 3, line 36, delete "IC 27-1-37.5-3.3" and insert "IC
	902	+	27-1-37.5-3.7".
	903	+	Page 3, line 38, delete "3.3." and insert "3.7.".
	904	+	Page 10, between lines 24 and 25, begin a new paragraph and insert:
	905	+	"(c) A health care provider that renders an unanticipated health
449	906		care service described in subsection (a) shall submit to the
450	907		utilization review entity documentation explaining why the
451		-	unanticipated health care service was medically necessary.
452		-	(b) The health plan shall not deny a claim described in subsection
453		-	(a) based solely on lack of prior authorization for the unanticipated
454		-	health care service.
455		-	(c) The health plan:
456		-	(1) shall not deny payment for a health care service that is
457		-	rendered in accordance with:
458		-	(A) a prior authorization; and
459		-	(B) all terms and conditions of the participating provider's
460		-	agreement or contract with the health plan; and
461		-	(2) may:
462		-	(A) require retrospective review of; and
463		-	(B) withhold payment for;
464		-	an unanticipated health care service described in subsection (a).
465		-	SECTION 23. IC 27-1-37.5-13.7 IS ADDED TO THE INDIANA
466		-	SEA 480 — Concur 12
467		-	CODE AS A NEW SECTION TO READ AS FOLLOWS
468		-	[EFFECTIVE JULY 1, 2025]: Sec. 13.7. (a) This section does not
469		-	apply to the following:
470		-	(1) A state employee health plan (as defined in
471		-	IC 5-10-8-6.7(a)).
472		-	(2) The Medicaid program.
473		-	(b) A utilization review entity may not require prior
474		-	authorization for the first twelve (12):
475		-	(1) physical therapy; or
476		-	(2) chiropractic;
477		-	visits of each new episode of care.
478		-	SECTION 24. IC 27-1-37.5-14, AS ADDED BY P.L.77-2018,
479		-	SECTION 2, IS AMENDED TO READ AS FOLLOWS [EFFECTIVE
480		-	JULY 1, 2025]: Sec. 14. A provision that:
481		-	(1) is contained in a policy or contract that is entered into,
482		-	amended, or renewed after June 30, 2018; 2025; and
483		-	(2) contradicts this chapter;
484		-	is void.
485		-	SECTION 25. IC 27-1-37.5-15, AS ADDED BY P.L.77-2018,
486		-	SECTION 2, IS AMENDED TO READ AS FOLLOWS [EFFECTIVE
487		-	JULY 1, 2025]: Sec. 15. A violation of this chapter by a health plan
488		-	utilization review entity is an unfair or deceptive act or practice in the
489		-	business of insurance under IC 27-4-1-4.
490		-	SECTION 26. IC 27-1-37.5-16, AS AMENDED BY P.L.265-2019,
491		-	SECTION 4, IS AMENDED TO READ AS FOLLOWS [EFFECTIVE
492		-	JULY 1, 2025]: Sec. 16. (a) Except as provided in subsection (b), the
493		-	department shall establish, post, and maintain on the department's
494		-	Internet web site website a standardized prior authorization form for
495		-	use by health care providers and health plans utilization review
496		-	entities for purposes of any notice or authorization required by a health
497		-	plan utilization review entity with respect to payment for a health care
498		-	service rendered to a covered individual.
499		-	(b) After December 31, 2020, a Medicaid managed care
500		-	organization (as defined in IC 12-7-2-126.9) shall use a standardized
501		-	prior authorization form prescribed by the office of the secretary of
502		-	family and social services.
503		-	SECTION 27. IC 27-1-37.5-17, AS ADDED BY P.L.190-2023,
504		-	SECTION 18, IS AMENDED TO READ AS FOLLOWS [EFFECTIVE
505		-	JULY 1, 2025]: Sec. 17. (a) As used in this section, "necessary
506		-	information" includes the results of any face-to-face clinical evaluation,
507		-	second opinion, or other clinical information that is directly applicable
508		-	to the requested health care service that may be required.
509		-	SEA 480 — Concur 13
510		-	(b) If a health plan utilization review entity makes an adverse
511		-	determination on a prior authorization request by a covered individual's
512		-	health care provider, the health plan utilization review entity must
513		-	offer the covered individual's health care provider the option to request
514		-	a peer to peer review by a clinical peer concerning the adverse
515		-	determination.
516		-	(c) A covered individual's health care provider may request a peer
517		-	to peer review by a clinical peer either in writing or electronically.
518		-	(d) If a peer to peer review by a clinical peer is requested under this
519		-	section:
520		-	(1) the health plan's utilization review entity's clinical peer and
521		-	the covered individual's health care provider or the health care
522		-	provider's designee shall make every effort to provide the peer to
523		-	peer review not later than seven (7) business days forty-eight
524		-	(48) hours (excluding weekends and state and federal legal
525		-	holidays) from the date of receipt by the health plan after the
526		-	utilization review entity receives of the request by the covered
527		-	individual's health care provider for a peer to peer review if the
528		-	health plan utilization review entity has received the necessary
529		-	information for the peer to peer review; and
530		-	(2) the health plan utilization review entity must have the peer
531		-	to peer review conducted between the clinical peer and the
532		-	covered individual's health care provider or the provider's
533		-	designee.
534		-	SECTION 28. IC 27-1-37.5-19 IS ADDED TO THE INDIANA
535		-	CODE AS A NEW SECTION TO READ AS FOLLOWS
536		-	[EFFECTIVE JULY 1, 2025]: Sec. 19. (a) A utilization review entity
537		-	shall make any current prior authorization requirements and
538		-	restrictions, including written clinical criteria, readily accessible on
539		-	the utilization review entity's website to covered individuals, health
540		-	care providers, and the general public. The prior authorization
541		-	requirements and restrictions must be described in detail and in
542		-	easily understandable language.
543		-	(b) A utilization review entity may not implement a new prior
544		-	authorization requirement or restriction or amend an existing
545		-	requirement or restriction unless:
546		-	(1) the utilization review entity's website has been updated to
547		-	reflect the new or amended requirement or restriction; and
548		-	(2) the utilization review entity provides written notice to
549		-	covered individuals and health care providers at least sixty
550		-	(60) days before the requirement or restriction is
551		-	implemented.
552		-	SEA 480 — Concur 14
553		-	(c) A utilization review entity shall make statistics available
554		-	regarding prior authorization approvals and denials on the
555		-	utilization review entity's website in a readily accessible format,
556		-	including statistics for the following categories:
557		-	(1) Health care provider specialty.
558		-	(2) Medication or diagnostic test or procedure.
559		-	(3) Indication offered.
560		-	(4) Reason for denial.
561		-	(5) If a decision was appealed.
562		-	(6) If a decision was approved or denied on appeal.
563		-	(7) The time between submission and the response.
564		-	(d) Not later than December 31 of each year, a utilization review
565		-	entity shall:
566		-	(1) prepare a report of the statistics compiled under
567		-	subsection (c); and
568		-	(2) submit the report to the department.
569		-	SECTION 29. IC 27-1-37.5-20 IS ADDED TO THE INDIANA
	908	+	unanticipated health care service was medically necessary.".
	909	+	Delete page 13.
	910	+	Page 14, delete lines 1 through 21, begin a new paragraph and
	911	+	ES 480—LS 7146/DI 141 22
	912	+	insert:
	913	+	"SECTION 27. IC 27-1-37.5-20 IS ADDED TO THE INDIANA
570	914		CODE AS A NEW SECTION TO READ AS FOLLOWS
571	915		[EFFECTIVE JULY 1, 2025]: Sec. 20. (a) A utilization review entity
572	916		must ensure that:
573	917		(1) all:
574		-	(A) adverse determinations based on medical necessity are
575		-	made; and
	918	+	(A) adverse determinations are made; and
576	919		(B) appeals are reviewed and decided;
577	920		by a clinical peer; and
578		-	(2) when making an adverse determination ~~based on medical~~
579		-	~~necessity or reviewing and~~ deciding an appeal, the clinical
580		-	~~peer is under the clinical~~ direction of a medical director of the
581		-	~~utilization review entity~~ who is:
	921	+	(2) when making an adverse determination or reviewing and
	922	+	deciding an appeal, the clinical peer is under the clinical
	923	+	direction of a medical director of the utilization review entity
	924	+	who is:
582	925		(A) responsible for the provision of health care services
583	926		provided to covered individuals; and
584	927		(B) a physician licensed in Indiana under IC 25-22.5.
585	928		(b) An appeal may not be reviewed or decided by a clinical peer
586	929		who:
587	930		(1) has a financial interest in the outcome of the appeal; or
588	931		(2) was involved in making the adverse determination that is
589	932		the subject of the appeal.
590		-	SECTION 30. IC 27-1-37.5-21 IS ADDED TO THE INDIANA
	933	+	SECTION 28. IC 27-1-37.5-21 IS ADDED TO THE INDIANA
591	934		CODE AS A NEW SECTION TO READ AS FOLLOWS
592	935		[EFFECTIVE JULY 1, 2025]: Sec. 21. A clinical peer who:
593	936		(1) makes an adverse determination; or
594	937		(2) reviews and decides an appeal;
595		-	SEA 480 — Concur 15
596	938		owes a duty to the covered individual to exercise the applicable
597		-	standard of care.
598		-	SECTION 31. IC 27-1-37.5-23 IS ADDED TO THE INDIANA
599		-	CODE AS A NEW SECTION TO READ AS FOLLOWS
600		-	[EFFECTIVE JULY 1, 2025]: Sec. 23. (a) The time frames set forth
601		-	in this section do not include weekends and state and federal legal
602		-	holidays.
603		-	(b) A utilization review entity shall respond to a request for
604		-	prior authorization as follows:
605		-	(1) If the request for prior authorization is for an urgent
606		-	health care service, the utilization review entity shall respond
607		-	with an authorization or adverse determination not later than
608		-	twenty-four (24) hours after receiving the request.
609		-	(2) If the request for prior authorization is:
610		-	(A) for a health care service other than the health care
611		-	services described in subdivision (1); or
612		-	(B) for a prescription drug;
613		-	the utilization review entity shall respond with an
614		-	authorization or adverse determination not later than
615		-	forty-eight (48) hours after receiving the request.
616		-	(c) If a utilization review entity issues an adverse determination
617		-	in a response under subsection (b), the response must include the
618		-	following information:
619		-	(1) Specific reasons for the adverse determination.
620		-	(2) Suggested alternatives to the requested health care service.
621		-	(d) A health care provider shall respond not later than
622		-	forty-eight (48) hours after receiving an adverse determination
623		-	under subsection (b) if the health care provider:
624		-	(1) needs to correct a typographical, clerical, or spelling
625		-	error; or
626		-	(2) accepts an alternative suggested by the utilization review
627		-	entity.
628		-	(e) Not later than forty-eight (48) hours after receiving a health
629		-	care provider's response under subsection (d), the utilization
630		-	review entity shall:
631		-	(1) render a prior authorization or adverse determination
632		-	based on the information provided in the health care
633		-	provider's response; and
634		-	(2) notify the health care provider of the authorization or
635		-	adverse determination.
636		-	(f) A health care provider may appeal an adverse determination
637		-	received under subsection (b) or (e). The health care provider shall
638		-	SEA 480 — Concur 16
639		-	notify the utilization review entity of an appeal not later than
640		-	forty-eight (48) hours after receiving notice of the adverse
641		-	determination.
642		-	(g) A utilization review entity shall respond to an appeal under
643		-	subsection (f) not later than forty-eight (48) hours after receiving
644		-	notice of the appeal.
645		-	SECTION 32. IC 27-1-37.5-24 IS ADDED TO THE INDIANA
646		-	CODE AS A NEW SECTION TO READ AS FOLLOWS
647		-	[EFFECTIVE JULY 1, 2025]: Sec. 24. (a) A utilization review entity
648		-	shall allow a covered individual and a covered individual's health
649		-	care provider at least twenty-four (24) hours (excluding weekends
650		-	and state and federal legal holidays) after an emergency admission
651		-	or provision of emergency health care services for the covered
652		-	individual or health care provider to notify the utilization review
653		-	entity of the emergency admission or provision of the emergency
654		-	health care service.
655		-	(b) A utilization review entity shall cover emergency health care
656		-	services necessary to screen and stabilize a covered individual. If
657		-	a health care provider certifies in writing to a utilization review
658		-	entity not later than seventy-two (72) hours (excluding weekends
659		-	and state and federal legal holidays) after a covered individual's
660		-	emergency admission that the covered individual's condition
661		-	required the emergency health care service, the certification will
662		-	create a presumption that the emergency health care service was
663		-	medically necessary. The presumption may be rebutted only if the
664		-	utilization review entity can establish, with clear and convincing
665		-	evidence, that the emergency health care service was not medically
666		-	necessary.
667		-	(c) The medical necessity of an emergency health care service
668		-	may not be based on whether the service was provided by a
669		-	participating or nonparticipating provider. Any restriction on the
670		-	coverage of an emergency health care service provided by a
671		-	nonparticipating provider may not be greater than the restriction
672		-	that applies when the service is provided by a participating
673		-	provider.
674		-	SECTION 33. IC 27-1-37.5-25 IS ADDED TO THE INDIANA
675		-	CODE AS A NEW SECTION TO READ AS FOLLOWS
676		-	[EFFECTIVE JULY 1, 2025]: Sec. 25. A utilization review entity
677		-	may not revoke, limit, condition, or restrict an authorization if the
678		-	health care provider begins providing the health care service not
679		-	later than forty-five (45) days (excluding weekends and state and
680		-	federal legal holidays) after the date the health care provider
681		-	SEA 480 — Concur 17
682		-	received the authorization.
683		-	SECTION 34. IC 27-1-37.5-26 IS ADDED TO THE INDIANA
684		-	CODE AS A NEW SECTION TO READ AS FOLLOWS
685		-	[EFFECTIVE JULY 1, 2025]: Sec. 26. (a) The authorization periods
686		-	in this section do not apply if:
687		-	(1) the health care provider has not begun providing the
688		-	health care service within forty-five (45) days (excluding
689		-	weekends and state and federal legal holidays) after receiving
690		-	the authorization as set forth in section 25 of this chapter; and
691		-	(2) the utilization review entity revokes, limits, conditions, or
692		-	restricts the authorization.
693		-	(b) An authorization for a health care service shall be valid for
694		-	at least one (1) year after the date the health care provider receives
695		-	the authorization.
696		-	(c) The authorization period under subsection (b) is effective
697		-	regardless of any changes in dosage for a prescription drug
698		-	prescribed by the health care provider.
699		-	SECTION 35. IC 27-1-37.5-27 IS ADDED TO THE INDIANA
	939	+	standard of care.".
	940	+	Page 16, delete lines 37 through 42.
	941	+	Page 17, delete lines 1 through 23, begin a new paragraph and
	942	+	insert:
	943	+	"SECTION 34. IC 27-1-37.5-27 IS ADDED TO THE INDIANA
700	944		CODE AS A NEW SECTION TO READ AS FOLLOWS
701	945		[EFFECTIVE JULY 1, 2025]: Sec. 27. (a) A utilization review entity
702	946		shall honor an authorization that was granted to a covered
703	947		individual by a previous utilization review entity for at least the
704	948		initial ninety (90) days of the covered individual's coverage under
705	949		a new health plan if:
706	950		(1) the utilization review entity receives information
707	951		documenting the authorization from the covered individual or
708	952		the covered individual's health care provider; and
709	953		(2) the authorization is for a health care service that is
	954	+	ES 480—LS 7146/DI 141 23
710	955		covered under the new health plan.
711	956		(b) During the time period described in subsection (a), a
712	957		utilization review entity may perform its own review of the prior
713	958		authorization request.
714	959		(c) If there is a change in:
715	960		(1) coverage of; or
716	961		(2) approval criteria for;
717	962		a previously authorized health care service, the change in coverage
718	963		or approval criteria may not affect a covered individual who
719	964		received authorization before the effective date of the change for
720	965		the remainder of the plan year.
721	966		(d) A utilization review entity shall continue to honor an
722	967		authorization that the utilization review entity granted to a covered
723	968		individual when the covered individual changes products under the
724		-	SEA 480 — Concur 18
725		-	same health insurance company.
726		-	SECTION 36. IC 27-1-37.5-28 IS ADDED TO THE INDIANA
	969	+	same health insurance company.".
	970	+	Renumber all SECTIONS consecutively.
	971	+	and when so amended that said bill do pass.
	972	+	(Reference is to SB 480 as printed February 14, 2025.)
	973	+	CARBAUGH
	974	+	Committee Vote: yeas 13, nays 0.
	975	+	_____
	976	+	HOUSE MOTION
	977	+	Mr. Speaker: I move that Engrossed Senate Bill 480 be amended to
	978	+	read as follows:
	979	+	Page 14, line 10, after "determinations" insert "based on medical
	980	+	necessity".
	981	+	Page 14, line 13, after "determination" insert "based on medical
	982	+	necessity".
	983	+	(Reference is to ESB 480 as printed April 8, 2025.)
	984	+	BARRETT
	985	+	ES 480—LS 7146/DI 141 24
	986	+	HOUSE MOTION
	987	+	Mr. Speaker: I move that Engrossed Senate Bill 480 be amended to
	988	+	read as follows:
	989	+	Page 5, between lines 8 and 9, begin a new paragraph and insert:
	990	+	"SECTION 10. IC 27-1-37.5-3.8 IS ADDED TO THE INDIANA
727	991		CODE AS A NEW SECTION TO READ AS FOLLOWS
728		-	[EFFECTIVE JULY 1, 2025]: Sec. 28. If a utilization review entity
729		-	fails to comply with the deadlines or other requirements under this
730		-	chapter, the health care service subject to prior authorization shall
731		-	be automatically deemed authorized by the utilization review
732		-	entity.
733		-	SECTION 37. IC 27-8-5.7-12 IS ADDED TO THE INDIANA
	992	+	[EFFECTIVE JULY 1, 2025]: Sec. 3.8. As used in this chapter,
	993	+	"episode of care" means the medical care ordered to be provided
	994	+	for a specific medical procedure, condition, or illness.".
	995	+	Page 11, between lines 41 and 42, begin a new paragraph and insert:
	996	+	"SECTION 22. IC 27-1-37.5-13.7 IS ADDED TO THE INDIANA
734	997		CODE AS A NEW SECTION TO READ AS FOLLOWS
735		-	[EFFECTIVE JULY 1, 2025]: Sec. 12. (a) This section applies to a
736		-	policy of accident and sickness insurance that is issued, delivered,
737		-	amended, or renewed after June 30, 2025.
738		-	(b) An insurer may not deny a claim for reimbursement for a
739		-	covered service or item provided to an insured on the sole basis
740		-	that the referring provider is an out of network provider.
741		-	SECTION 38. IC 27-13-36.2-10 IS ADDED TO THE INDIANA
742		-	CODE AS A NEW SECTION TO READ AS FOLLOWS
743		-	[EFFECTIVE JULY 1, 2025]: Sec. 10. (a) This section applies to an
744		-	individual contract and a group contract that is entered into,
745		-	delivered, amended, or renewed after June 30, 2025.
746		-	(b) A health maintenance organization may not deny a claim for
747		-	reimbursement for a covered service or item provided to an
748		-	enrollee on the sole basis that the referring provider is an out of
749		-	network provider.
750		-	SEA 480 — Concur President of the Senate
751		-	President Pro Tempore
752		-	Speaker of the House of Representatives
753		-	Governor of the State of Indiana
754		-	Date: Time:
755		-	SEA 480 — Concur
	998	+	[EFFECTIVE JULY 1, 2025]: Sec. 13.7. (a) This section does not
	999	+	apply to the following:
	1000	+	(1) A state employee health plan (as defined in
	1001	+	IC 5-10-8-6.7(a)).
	1002	+	(2) The Medicaid program.
	1003	+	(b) A utilization review entity may not require prior
	1004	+	authorization for the first twelve (12):
	1005	+	(1) physical therapy; or
	1006	+	(2) chiropractic;
	1007	+	visits of each new episode of care.".
	1008	+	Renumber all SECTIONS consecutively.
	1009	+	(Reference is to ESB 480 as printed April 8, 2025.)
	1010	+	MAYFIELD
	1011	+	ES 480—LS 7146/DI 141