IC 27-1-37.5-20: Use of clinical peer when an adverse determination is made or when reviewing or deciding an appeal

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.