First Regular Session of the 124th General Assembly (2025)
PRINTING CODE. Amendments: Whenever an existing statute (or a section of the Indiana
Constitution) is being amended, the text of the existing provision will appear in this style type,
additions will appear in this style type, and deletions will appear in this style type.
Additions: Whenever a new statutory provision is being enacted (or a new constitutional
provision adopted), the text of the new provision will appear in this style type. Also, the
word NEW will appear in that style type in the introductory clause of each SECTION that adds
a new provision to the Indiana Code or the Indiana Constitution.
Conflict reconciliation: Text in a statute in this style type or this style type reconciles conflicts
between statutes enacted by the 2024 Regular Session of the General Assembly.
SENATE ENROLLED ACT No. 480
AN ACT to amend the Indiana Code concerning insurance.
Be it enacted by the General Assembly of the State of Indiana:
SECTION 1. IC 5-10-8-19, AS ADDED BY P.L.77-2018,
SECTION 1, IS AMENDED TO READ AS FOLLOWS [EFFECTIVE
JULY 1, 2025]: Sec. 19. A self-insurance program established under
section 7(b) of this chapter to provide health care coverage shall
comply with the prior authorization requirements that apply to a health
plan utilization review entity under IC 27-1-37.5.
SECTION 2. IC 27-1-37.5-1, AS AMENDED BY P.L.190-2023,
SECTION 13, IS AMENDED TO READ AS FOLLOWS [EFFECTIVE
JULY 1, 2025]: Sec. 1. (a) Except as provided in sections 10, 11, 12,
13, and 13.5 of this chapter, this chapter applies beginning September
1, 2018.
(b) (a) This chapter does not apply to a step therapy protocol
exception procedure under IC 5-10-8-17, IC 27-8-5-30, or
IC 27-13-7-23.
(c) (b) This chapter does not apply to a health plan that is offered by
a local unit public employer under a program of group health insurance
provided under IC 5-10-8-2.6.
(c) This chapter does not apply to health care services provided
under the following state Medicaid waivers:
(1) Pathways for aging.
(2) Health and wellness.
(d) This chapter does not apply to the extent that it is preempted
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by a federal statute or regulation relating to the Medicaid program
under Title XIX of the federal Social Security Act (42 U.S.C. 1396
et seq.).
SECTION 3. IC 27-1-37.5-1.5, AS ADDED BY P.L.190-2023,
SECTION 14, IS AMENDED TO READ AS FOLLOWS [EFFECTIVE
JULY 1, 2025]: Sec. 1.5. As used in this chapter, "adverse
determination" means a denial of a request for benefits decision by a
utilization review entity to deny, reduce, or terminate benefit
coverage of a health care service furnished or proposed to be
furnished to a covered individual on the grounds that the health care
service: or item:
(1) is not medically necessary, appropriate, effective, or efficient;
(2) is not being provided in or at an appropriate health care setting
or level of care; or
(3) is experimental or investigational.
SECTION 4. IC 27-1-37.5-1.6 IS ADDED TO THE INDIANA
CODE AS A NEW SECTION TO READ AS FOLLOWS
[EFFECTIVE JULY 1, 2025]: Sec. 1.6. As used in this chapter,
"authorization" means a determination by a utilization review
entity that:
(1) a health care service:
(A) has been reviewed; and
(B) based on the information provided, satisfies the
utilization review entity's requirements for medical
necessity; and
(2) payment will be made for the health care service.
SECTION 5. IC 27-1-37.5-1.7, AS ADDED BY P.L.190-2023,
SECTION 15, IS AMENDED TO READ AS FOLLOWS [EFFECTIVE
JULY 1, 2025]: Sec. 1.7. As used in this chapter, "clinical peer" means
a practitioner or other health care provider who either: the following:
(1) Except as provided in subdivision (3), for a review of a
request from a physician, a physician who:
(A) holds a current and valid license in any United States
jurisdiction; under IC 25-22.5, (2) has been granted
reciprocity in the state, under IC 25-1-21, if reciprocity exists,
or (3) holds a license that is part of a compact in which the
state Indiana has entered;
(B) is certified in the same specialty as the physician under
review, as recognized by:
(i) the American Board of Medical Specialties; or
(ii) the American Osteopathic Association; and
(C) if the review specifically concerns subspecialty care, is
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certified in the same subspecialty as the physician under
review, as recognized by:
(i) the American Board of Medical Specialties; or
(ii) the American Osteopathic Association.
(2) For a review of a request from an advanced practice
registered nurse, an advanced practice registered nurse who:
(A) holds a current and valid license under IC 25-23-1 or
has been granted reciprocity under IC 25-1-21, if
reciprocity exists, or holds a license that is part of a
compact in which Indiana has entered; and
(B) holds equivalent or similar:
(i) population focus; and
(ii) role specialty;
as the advanced practice registered nurse who is subject to
the review.
(3) For a review of a request from a primary care physician
(as defined in IC 25-22.5-5.5-1.5), a physician who:
(A) holds a current and valid license under IC 25-22.5, has
been granted reciprocity under IC 25-1-21, if reciprocity
exists, or holds a license that is part of a compact in which
Indiana has entered;
(B) is certified in the same general practice of medicine
under review, as recognized by:
(i) the American Board of Medical Specialties;
(ii) the American Board of Pediatrics; or
(iii) the American Osteopathic Association; and
(C) has been actively engaged in general practice for at
least three (3) years.
(4) For a review of a request from a practitioner or health
care provider other than those specified in subdivisions (1)
through (3), a practitioner or health care provider who:
(A) holds a current and valid license in Indiana;
(B) has been granted reciprocity in Indiana, if reciprocity
exists; or
(C) holds a license that is part of a compact in which
Indiana has entered.
SECTION 6. IC 27-1-37.5-1.8 IS ADDED TO THE INDIANA
CODE AS A NEW SECTION TO READ AS FOLLOWS
[EFFECTIVE JULY 1, 2025]: Sec. 1.8. As used in this chapter,
"clinical criteria" means:
(1) written policies;
(2) written screen procedures;
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(3) drug formularies or lists of covered drugs;
(4) determination rules;
(5) determination abstracts;
(6) clinical protocols;
(7) practice guidelines;
(8) medical protocols; and
(9) any other criteria or rationale;
used by the utilization review entity to determine the medical
necessity of a health care service.
SECTION 7. IC 27-1-37.5-1.9 IS ADDED TO THE INDIANA
CODE AS A NEW SECTION TO READ AS FOLLOWS
[EFFECTIVE JULY 1, 2025]: Sec. 1.9. (a) As used in this chapter,
"cosmetic surgery" means any procedure that:
(1) is directed at improving the patient's appearance; and
(2) does not meaningfully:
(A) promote the proper function of the body; or
(B) prevent or treat illness or disease.
(b) The term does not include the following:
(1) A procedure that is necessary to ameliorate a deformity
arising from or directly related to a:
(A) congenital abnormality;
(B) personal injury resulting from an accident or trauma;
or
(C) disfiguring disease.
(2) A procedure related to the treatment of breast cancer.
SECTION 8. IC 27-1-37.5-2, AS ADDED BY P.L.77-2018,
SECTION 2, IS AMENDED TO READ AS FOLLOWS [EFFECTIVE
JULY 1, 2025]: Sec. 2. As used in this chapter, "covered individual"
means an individual who is covered under a health plan. The term
includes a covered individual's legally authorized representative.
SECTION 9. IC 27-1-37.5-3.7 IS ADDED TO THE INDIANA
CODE AS A NEW SECTION TO READ AS FOLLOWS
[EFFECTIVE JULY 1, 2025]: Sec. 3.7. As used in this chapter,
"emergency health care service" means a health care service that
is provided in an emergency facility after the sudden onset of a
medical condition that manifests itself by symptoms of sufficient
severity, including severe pain, that the absence of immediate
medical attention could reasonably be expected by a prudent
layperson who possesses average knowledge of health and medicine
to:
(1) place an individual's health in serious jeopardy;
(2) result in serious impairment to the individual's bodily
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function; or
(3) result in serious dysfunction of any bodily organ or part of
the individual.
SECTION 10. IC 27-1-37.5-3.8 IS ADDED TO THE INDIANA
CODE AS A NEW SECTION TO READ AS FOLLOWS
[EFFECTIVE JULY 1, 2025]: Sec. 3.8. As used in this chapter,
"episode of care" means the medical care ordered to be provided
for a specific medical procedure, condition, or illness.
SECTION 11. IC 27-1-37.5-3.9 IS ADDED TO THE INDIANA
CODE AS A NEW SECTION TO READ AS FOLLOWS
[EFFECTIVE JULY 1, 2025]: Sec. 3.9. (a) As used in this chapter,
except as provided in subsection (b), "health care provider" means
an individual who holds a license issued by a board described in
IC 25-0.5-11.
(b) The term does not include the following:
(1) A dentist licensed under IC 25-14.
(2) An optometrist licensed under IC 25-24.
(3) A veterinarian licensed under IC 25-38.1.
SECTION 12. IC 27-1-37.5-4, AS ADDED BY P.L.77-2018,
SECTION 2, IS AMENDED TO READ AS FOLLOWS [EFFECTIVE
JULY 1, 2025]: Sec. 4. (a) As used in this chapter, "health care service"
means a health care related service or product rendered or sold
procedure, treatment, or service provided by:
(1) a health care facility (as defined in IC 16-18-2-161(a));
(2) an ambulatory outpatient surgical center (as defined in
IC 16-18-2-14); or
(3) a health care provider within the scope of practice of the
health care provider's license or legal authorization.
including hospital, medical, surgical, mental health, and substance
abuse services or products. The term includes the provision of
pharmaceutical products or services or durable medical
equipment.
(b) The term does not include the following:
(1) Dental services.
(2) Vision services.
(3) Long term rehabilitation treatment. Cosmetic surgery.
(4) Pharmaceutical services or products.
SECTION 13. IC 27-1-37.5-5.4 IS ADDED TO THE INDIANA
CODE AS A NEW SECTION TO READ AS FOLLOWS
[EFFECTIVE JULY 1, 2025]: Sec. 5.4. As used in this chapter,
"medically necessary" means a health care service that a prudent
health care provider would provide to a patient for the purpose of
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preventing, diagnosing, or treating an illness, injury, disease, or
symptoms in a manner that is:
(1) in accordance with generally accepted standards of
medical practice;
(2) clinically appropriate in terms of type, frequency, extent,
site, and duration; and
(3) not primarily for:
(A) the economic benefit of the health plan or purchaser;
or
(B) the convenience of the health plan, patient, treating
physician, or other health care provider.
SECTION 14. IC 27-1-37.5-7, AS ADDED BY P.L.77-2018,
SECTION 2, IS AMENDED TO READ AS FOLLOWS [EFFECTIVE
JULY 1, 2025]: Sec. 7. As used in this chapter, "prior authorization"
means a practice implemented by a health plan through which coverage
of a health care service is dependent on the covered individual or
health care provider obtaining approval from the health plan before the
health care service is rendered. The term includes prospective or
utilization review procedures conducted before a health care service is
rendered. the process by which a utilization review entity
determines the medical necessity of an otherwise covered health
care service before the health care service is rendered. The term
includes a utilization review entity's requirement that a covered
individual or health care provider notify the utilization review
entity prior to providing a health care service.
SECTION 15. IC 27-1-37.5-8 IS REPEALED [EFFECTIVE JULY
1, 2025]. Sec. 8. As used in this chapter, "urgent care situation" means
a situation in which a covered individual's treating physician has
determined that the covered individual's condition is likely to result in:
(1) adverse health consequences or serious jeopardy to the
covered individual's life, health, or safety; or
(2) due to the covered individual's psychological state, serious
jeopardy to the life, health, or safety of another individual;
unless treatment of the covered individual's condition for which prior
authorization is sought occurs earlier than the period generally
considered by the medical profession to be reasonable to treat routine
or non-life threatening conditions.
SECTION 16. IC 27-1-37.5-8.1 IS ADDED TO THE INDIANA
CODE AS A NEW SECTION TO READ AS FOLLOWS
[EFFECTIVE JULY 1, 2025]: Sec. 8.1. As used in this chapter,
"urgent health care service" means a health care service in which
the application of the time period for making a nonexpedited prior
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authorization, in the opinion of a physician with knowledge of the
covered individual's medical condition, could:
(1) seriously jeopardize:
(A) the life or health of the covered individual; or
(B) the covered individual's ability to regain maximum
function; or
(2) subject the covered individual to severe pain that cannot
be adequately managed without the health care service.
The term includes a mental and behavioral health care service.
SECTION 17. IC 27-1-37.5-8.3 IS ADDED TO THE INDIANA
CODE AS A NEW SECTION TO READ AS FOLLOWS
[EFFECTIVE JULY 1, 2025]: Sec. 8.3. As used in this chapter,
"utilization review entity" means an individual or entity that
performs prior authorization for one (1) or more of the following:
(1) An employer who employs a covered individual.
(2) A health plan.
(3) A preferred provider organization.
(4) Any other individual or entity that:
(A) provides;
(B) offers to provide; or
(C) administers;
hospital, outpatient, medical, prescription drug, or other
health benefits to a covered individual.
SECTION 18. IC 27-1-37.5-9 IS REPEALED [EFFECTIVE JULY
1, 2025]. Sec. 9. (a) A health plan shall make available to participating
providers on the health plan's Internet web site or portal the applicable
CPT code for the specific health care services for which prior
authorization is required.
(b) A health plan shall make available to participating providers, on
the health plan's Internet web site or portal, a list of the health plan's
prior authorization requirements, including specific information that a
provider must submit to establish a complete request for prior
authorization. This subsection does not prevent a health plan from
requiring specific additional information upon review of the request for
prior authorization.
(c) A health plan shall, not less than forty-five (45) days before the
prior authorization requirement becomes effective, disclose to a
participating provider any new prior authorization requirement.
(d) A disclosure made under subsection (c) must:
(1) be sent via electronic or United States mail and conspicuously
labeled "Notice of Changes to Prior Authorization Requirements";
and
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(2) specifically identify the location on the health plan's Internet
web site or portal of the new prior authorization requirement.
However, a health plan is considered to have met the requirements of
this subsection if the health plan conspicuously posts the information
required by this subsection, including the effective date of the new
prior authorization requirement, on the health plan's Internet web site.
(e) A participating provider shall, not more than seven (7) days after
the change is made, notify the health plan of a change in the
participating provider's electronic or United States mail address.
SECTION 19. IC 27-1-37.5-10, AS ADDED BY P.L.208-2018,
SECTION 8, IS AMENDED TO READ AS FOLLOWS [EFFECTIVE
JULY 1, 2025]: Sec. 10. (a) This section applies to a request for prior
authorization delivered to a health plan after December 31, 2019. does
not apply to prior authorization for a prescription drug.
(b) A health plan utilization review entity shall accept a request for
prior authorization delivered to the health plan utilization review
entity by a covered individual's health care provider through a secure
electronic transmission or an application programming interface. A
health care provider shall submit a request for prior authorization
through a secure electronic transmission or an application
programming interface. A health plan utilization review entity shall
provide for:
(1) a secure electronic transmission or an application
programming interface; and
(2) acknowledgment of receipt, by use of a transaction number or
another reference code;
of a request for prior authorization and any supporting information.
(c) Subsection (b) does not apply and a health plan utilization
review entity that requires prior authorization shall accept a request for
prior authorization that is not submitted through a secure electronic
transmission or an application programming interface if a covered
individual's health care provider and the health plan utilization review
entity have entered into an agreement under which the health plan
utilization review entity agrees to process prior authorization requests
that are not submitted through a secure electronic transmission or an
application programming interface because:
(1) a secure electronic transmission or an application
programming interface of prior authorization requests would
cause financial hardship for the health care provider;
(2) the area in which the health care provider is located lacks
sufficient Internet access; or
(3) the health care provider has an insufficient number of covered
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individuals as patients or customers, as determined by the
commissioner, to warrant the financial expense that compliance
with subsection (b) would require.
(d) If a covered individual's health care provider is described in
subsection (c), the health plan utilization review entity shall accept
from the health care provider a request for prior authorization as
follows:
(1) The prior authorization request must be made on the
standardized prior authorization form established by the
department under section 16 of this chapter.
(2) The health plan utilization review entity shall provide for a
secure electronic transmission or an application programming
interface and acknowledgement acknowledgment of receipt of
the standardized prior authorization form and any supporting
information for the prior authorization by use of a transaction
number or another reference code.
SECTION 20. IC 27-1-37.5-11 IS REPEALED [EFFECTIVE JULY
1, 2025]. Sec. 11. (a) This section applies to a prior authorization
request delivered to a health plan after December 31, 2019.
(b) A health plan shall respond to a request delivered under section
10 of this chapter as follows:
(1) If the request is delivered under section 10(b) of this chapter,
the health plan shall immediately send to the requesting health
care provider an electronic receipt for the request.
(2) If the request is for an urgent care situation, the health plan
shall respond with a prior authorization determination not more
than forty-eight (48) hours after receiving the request.
(3) If the request is for a nonurgent care situation, the health plan
shall respond with a prior authorization determination not more
than five (5) business days after receiving the request.
(c) If a request delivered under section 10 of this chapter is
incomplete:
(1) the health plan shall respond within the period required by
subsection (b) and indicate the specific additional information
required to process the request;
(2) if the request was delivered under section 10(b) of this
chapter, upon receiving the response under subdivision (1), the
health care provider shall immediately send to the health plan an
electronic receipt for the response made under subdivision (1);
and
(3) if the request is for an urgent care situation, the health care
provider shall respond to the request for additional information
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not more than forty-eight (48) hours after the health care provider
receives the response under subdivision (1).
(d) If a request delivered under section 10 of this chapter is denied,
the health plan shall respond within the period required by subsection
(b) and indicate the specific reason for the denial in clear and easy to
understand language.
SECTION 21. IC 27-1-37.5-12, AS ADDED BY P.L.77-2018,
SECTION 2, IS AMENDED TO READ AS FOLLOWS [EFFECTIVE
JULY 1, 2025]: Sec. 12. (a) This section applies to a claim for a health
care service rendered by a participating health care provider:
(1) for which:
(A) prior authorization is requested after December 31, 2019;
June 30, 2025; and
(B) a health plan utilization review entity gives prior
authorization; and
(2) that is rendered in accordance with
(A) the prior authorization. and
(B) all terms and conditions of the participating provider's
agreement or contract with the health plan.
(b) The health plan utilization review entity shall not deny the
claim described in subsection (a) unless:
(1) the:
(A) request for prior authorization; or
(B) claim;
contains fraudulent or materially incorrect information; or
(1) the health care provider knowingly and materially
misrepresented the health care service in the prior
authorization request with the specific intent to deceive and
obtain an unlawful payment from the utilization review
entity;
(2) the health care service was no longer a covered benefit on
the date the health care service was provided;
(3) the health care provider was no longer contracted with the
patient's health plan on the date the health care service was
provided;
(4) the health care provider failed to meet the utilization
review entity's timely filing requirements;
(5) the utilization review entity does not have liability for the
claim; or
(2) (6) the covered individual is patient was not covered under
the health plan on the date on which the health care service is was
rendered.
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(c) If:
(1) the claim described in subsection (a) contains an unintentional
and inaccurate inconsistency with the request for prior
authorization; and
(2) the inconsistency results in denial of the claim;
the health care provider may resubmit the claim with accurate,
corrected information.
SECTION 22. IC 27-1-37.5-13, AS ADDED BY P.L.77-2018,
SECTION 2, IS AMENDED TO READ AS FOLLOWS [EFFECTIVE
JULY 1, 2025]: Sec. 13. (a) This section applies to a claim filed after
December 31, 2018, June 30, 2025, for a medically necessary health
care service rendered by a participating health care provider, the
necessity of which:
(1) is not anticipated at the time prior authorization is obtained for
of scheduling another health care service that:
(A) was authorized by the utilization review entity; or
(B) is not subject to a prior authorization requirement; and
(2) is determined at the time the other health care service is
rendered.
(b) A utilization review entity may not:
(1) require retrospective review of; or
(2) deny a claim based solely on lack of prior authorization
for;
an unanticipated health care service described in subsection (a).
(c) A health care provider that renders an unanticipated health
care service described in subsection (a) shall submit to the
utilization review entity documentation explaining why the
unanticipated health care service was medically necessary.
(b) The health plan shall not deny a claim described in subsection
(a) based solely on lack of prior authorization for the unanticipated
health care service.
(c) The health plan:
(1) shall not deny payment for a health care service that is
rendered in accordance with:
(A) a prior authorization; and
(B) all terms and conditions of the participating provider's
agreement or contract with the health plan; and
(2) may:
(A) require retrospective review of; and
(B) withhold payment for;
an unanticipated health care service described in subsection (a).
SECTION 23. IC 27-1-37.5-13.7 IS ADDED TO THE INDIANA
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CODE AS A NEW SECTION TO READ AS FOLLOWS
[EFFECTIVE JULY 1, 2025]: Sec. 13.7. (a) This section does not
apply to the following:
(1) A state employee health plan (as defined in
IC 5-10-8-6.7(a)).
(2) The Medicaid program.
(b) A utilization review entity may not require prior
authorization for the first twelve (12):
(1) physical therapy; or
(2) chiropractic;
visits of each new episode of care.
SECTION 24. IC 27-1-37.5-14, AS ADDED BY P.L.77-2018,
SECTION 2, IS AMENDED TO READ AS FOLLOWS [EFFECTIVE
JULY 1, 2025]: Sec. 14. A provision that:
(1) is contained in a policy or contract that is entered into,
amended, or renewed after June 30, 2018; 2025; and
(2) contradicts this chapter;
is void.
SECTION 25. IC 27-1-37.5-15, AS ADDED BY P.L.77-2018,
SECTION 2, IS AMENDED TO READ AS FOLLOWS [EFFECTIVE
JULY 1, 2025]: Sec. 15. A violation of this chapter by a health plan
utilization review entity is an unfair or deceptive act or practice in the
business of insurance under IC 27-4-1-4.
SECTION 26. IC 27-1-37.5-16, AS AMENDED BY P.L.265-2019,
SECTION 4, IS AMENDED TO READ AS FOLLOWS [EFFECTIVE
JULY 1, 2025]: Sec. 16. (a) Except as provided in subsection (b), the
department shall establish, post, and maintain on the department's
Internet web site website a standardized prior authorization form for
use by health care providers and health plans utilization review
entities for purposes of any notice or authorization required by a health
plan utilization review entity with respect to payment for a health care
service rendered to a covered individual.
(b) After December 31, 2020, a Medicaid managed care
organization (as defined in IC 12-7-2-126.9) shall use a standardized
prior authorization form prescribed by the office of the secretary of
family and social services.
SECTION 27. IC 27-1-37.5-17, AS ADDED BY P.L.190-2023,
SECTION 18, IS AMENDED TO READ AS FOLLOWS [EFFECTIVE
JULY 1, 2025]: Sec. 17. (a) As used in this section, "necessary
information" includes the results of any face-to-face clinical evaluation,
second opinion, or other clinical information that is directly applicable
to the requested health care service that may be required.
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(b) If a health plan utilization review entity makes an adverse
determination on a prior authorization request by a covered individual's
health care provider, the health plan utilization review entity must
offer the covered individual's health care provider the option to request
a peer to peer review by a clinical peer concerning the adverse
determination.
(c) A covered individual's health care provider may request a peer
to peer review by a clinical peer either in writing or electronically.
(d) If a peer to peer review by a clinical peer is requested under this
section:
(1) the health plan's utilization review entity's clinical peer and
the covered individual's health care provider or the health care
provider's designee shall make every effort to provide the peer to
peer review not later than seven (7) business days forty-eight
(48) hours (excluding weekends and state and federal legal
holidays) from the date of receipt by the health plan after the
utilization review entity receives of the request by the covered
individual's health care provider for a peer to peer review if the
health plan utilization review entity has received the necessary
information for the peer to peer review; and
(2) the health plan utilization review entity must have the peer
to peer review conducted between the clinical peer and the
covered individual's health care provider or the provider's
designee.
SECTION 28. IC 27-1-37.5-19 IS ADDED TO THE INDIANA
CODE AS A NEW SECTION TO READ AS FOLLOWS
[EFFECTIVE JULY 1, 2025]: Sec. 19. (a) A utilization review entity
shall make any current prior authorization requirements and
restrictions, including written clinical criteria, readily accessible on
the utilization review entity's website to covered individuals, health
care providers, and the general public. The prior authorization
requirements and restrictions must be described in detail and in
easily understandable language.
(b) A utilization review entity may not implement a new prior
authorization requirement or restriction or amend an existing
requirement or restriction unless:
(1) the utilization review entity's website has been updated to
reflect the new or amended requirement or restriction; and
(2) the utilization review entity provides written notice to
covered individuals and health care providers at least sixty
(60) days before the requirement or restriction is
implemented.
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(c) A utilization review entity shall make statistics available
regarding prior authorization approvals and denials on the
utilization review entity's website in a readily accessible format,
including statistics for the following categories:
(1) Health care provider specialty.
(2) Medication or diagnostic test or procedure.
(3) Indication offered.
(4) Reason for denial.
(5) If a decision was appealed.
(6) If a decision was approved or denied on appeal.
(7) The time between submission and the response.
(d) Not later than December 31 of each year, a utilization review
entity shall:
(1) prepare a report of the statistics compiled under
subsection (c); and
(2) submit the report to the department.
SECTION 29. IC 27-1-37.5-20 IS ADDED TO THE INDIANA
CODE AS A NEW SECTION TO READ AS FOLLOWS
[EFFECTIVE JULY 1, 2025]: Sec. 20. (a) A utilization review entity
must ensure that:
(1) all:
(A) adverse determinations based on medical necessity are
made; and
(B) appeals are reviewed and decided;
by a clinical peer; and
(2) when making an adverse determination based on medical
necessity or reviewing and deciding an appeal, the clinical
peer is under the clinical direction of a medical director of the
utilization review entity who is:
(A) responsible for the provision of health care services
provided to covered individuals; and
(B) a physician licensed in Indiana under IC 25-22.5.
(b) An appeal may not be reviewed or decided by a clinical peer
who:
(1) has a financial interest in the outcome of the appeal; or
(2) was involved in making the adverse determination that is
the subject of the appeal.
SECTION 30. IC 27-1-37.5-21 IS ADDED TO THE INDIANA
CODE AS A NEW SECTION TO READ AS FOLLOWS
[EFFECTIVE JULY 1, 2025]: Sec. 21. A clinical peer who:
(1) makes an adverse determination; or
(2) reviews and decides an appeal;
SEA 480 — Concur 15
owes a duty to the covered individual to exercise the applicable
standard of care.
SECTION 31. IC 27-1-37.5-23 IS ADDED TO THE INDIANA
CODE AS A NEW SECTION TO READ AS FOLLOWS
[EFFECTIVE JULY 1, 2025]: Sec. 23. (a) The time frames set forth
in this section do not include weekends and state and federal legal
holidays.
(b) A utilization review entity shall respond to a request for
prior authorization as follows:
(1) If the request for prior authorization is for an urgent
health care service, the utilization review entity shall respond
with an authorization or adverse determination not later than
twenty-four (24) hours after receiving the request.
(2) If the request for prior authorization is:
(A) for a health care service other than the health care
services described in subdivision (1); or
(B) for a prescription drug;
the utilization review entity shall respond with an
authorization or adverse determination not later than
forty-eight (48) hours after receiving the request.
(c) If a utilization review entity issues an adverse determination
in a response under subsection (b), the response must include the
following information:
(1) Specific reasons for the adverse determination.
(2) Suggested alternatives to the requested health care service.
(d) A health care provider shall respond not later than
forty-eight (48) hours after receiving an adverse determination
under subsection (b) if the health care provider:
(1) needs to correct a typographical, clerical, or spelling
error; or
(2) accepts an alternative suggested by the utilization review
entity.
(e) Not later than forty-eight (48) hours after receiving a health
care provider's response under subsection (d), the utilization
review entity shall:
(1) render a prior authorization or adverse determination
based on the information provided in the health care
provider's response; and
(2) notify the health care provider of the authorization or
adverse determination.
(f) A health care provider may appeal an adverse determination
received under subsection (b) or (e). The health care provider shall
SEA 480 — Concur 16
notify the utilization review entity of an appeal not later than
forty-eight (48) hours after receiving notice of the adverse
determination.
(g) A utilization review entity shall respond to an appeal under
subsection (f) not later than forty-eight (48) hours after receiving
notice of the appeal.
SECTION 32. IC 27-1-37.5-24 IS ADDED TO THE INDIANA
CODE AS A NEW SECTION TO READ AS FOLLOWS
[EFFECTIVE JULY 1, 2025]: Sec. 24. (a) A utilization review entity
shall allow a covered individual and a covered individual's health
care provider at least twenty-four (24) hours (excluding weekends
and state and federal legal holidays) after an emergency admission
or provision of emergency health care services for the covered
individual or health care provider to notify the utilization review
entity of the emergency admission or provision of the emergency
health care service.
(b) A utilization review entity shall cover emergency health care
services necessary to screen and stabilize a covered individual. If
a health care provider certifies in writing to a utilization review
entity not later than seventy-two (72) hours (excluding weekends
and state and federal legal holidays) after a covered individual's
emergency admission that the covered individual's condition
required the emergency health care service, the certification will
create a presumption that the emergency health care service was
medically necessary. The presumption may be rebutted only if the
utilization review entity can establish, with clear and convincing
evidence, that the emergency health care service was not medically
necessary.
(c) The medical necessity of an emergency health care service
may not be based on whether the service was provided by a
participating or nonparticipating provider. Any restriction on the
coverage of an emergency health care service provided by a
nonparticipating provider may not be greater than the restriction
that applies when the service is provided by a participating
provider.
SECTION 33. IC 27-1-37.5-25 IS ADDED TO THE INDIANA
CODE AS A NEW SECTION TO READ AS FOLLOWS
[EFFECTIVE JULY 1, 2025]: Sec. 25. A utilization review entity
may not revoke, limit, condition, or restrict an authorization if the
health care provider begins providing the health care service not
later than forty-five (45) days (excluding weekends and state and
federal legal holidays) after the date the health care provider
SEA 480 — Concur 17
received the authorization.
SECTION 34. IC 27-1-37.5-26 IS ADDED TO THE INDIANA
CODE AS A NEW SECTION TO READ AS FOLLOWS
[EFFECTIVE JULY 1, 2025]: Sec. 26. (a) The authorization periods
in this section do not apply if:
(1) the health care provider has not begun providing the
health care service within forty-five (45) days (excluding
weekends and state and federal legal holidays) after receiving
the authorization as set forth in section 25 of this chapter; and
(2) the utilization review entity revokes, limits, conditions, or
restricts the authorization.
(b) An authorization for a health care service shall be valid for
at least one (1) year after the date the health care provider receives
the authorization.
(c) The authorization period under subsection (b) is effective
regardless of any changes in dosage for a prescription drug
prescribed by the health care provider.
SECTION 35. IC 27-1-37.5-27 IS ADDED TO THE INDIANA
CODE AS A NEW SECTION TO READ AS FOLLOWS
[EFFECTIVE JULY 1, 2025]: Sec. 27. (a) A utilization review entity
shall honor an authorization that was granted to a covered
individual by a previous utilization review entity for at least the
initial ninety (90) days of the covered individual's coverage under
a new health plan if:
(1) the utilization review entity receives information
documenting the authorization from the covered individual or
the covered individual's health care provider; and
(2) the authorization is for a health care service that is
covered under the new health plan.
(b) During the time period described in subsection (a), a
utilization review entity may perform its own review of the prior
authorization request.
(c) If there is a change in:
(1) coverage of; or
(2) approval criteria for;
a previously authorized health care service, the change in coverage
or approval criteria may not affect a covered individual who
received authorization before the effective date of the change for
the remainder of the plan year.
(d) A utilization review entity shall continue to honor an
authorization that the utilization review entity granted to a covered
individual when the covered individual changes products under the
SEA 480 — Concur 18
same health insurance company.
SECTION 36. IC 27-1-37.5-28 IS ADDED TO THE INDIANA
CODE AS A NEW SECTION TO READ AS FOLLOWS
[EFFECTIVE JULY 1, 2025]: Sec. 28. If a utilization review entity
fails to comply with the deadlines or other requirements under this
chapter, the health care service subject to prior authorization shall
be automatically deemed authorized by the utilization review
entity.
SECTION 37. IC 27-8-5.7-12 IS ADDED TO THE INDIANA
CODE AS A NEW SECTION TO READ AS FOLLOWS
[EFFECTIVE JULY 1, 2025]: Sec. 12. (a) This section applies to a
policy of accident and sickness insurance that is issued, delivered,
amended, or renewed after June 30, 2025.
(b) An insurer may not deny a claim for reimbursement for a
covered service or item provided to an insured on the sole basis
that the referring provider is an out of network provider.
SECTION 38. IC 27-13-36.2-10 IS ADDED TO THE INDIANA
CODE AS A NEW SECTION TO READ AS FOLLOWS
[EFFECTIVE JULY 1, 2025]: Sec. 10. (a) This section applies to an
individual contract and a group contract that is entered into,
delivered, amended, or renewed after June 30, 2025.
(b) A health maintenance organization may not deny a claim for
reimbursement for a covered service or item provided to an
enrollee on the sole basis that the referring provider is an out of
network provider.
SEA 480 — Concur President of the Senate
President Pro Tempore
Speaker of the House of Representatives
Governor of the State of Indiana
Date: Time:
SEA 480 — Concur