{"data":{"id":"us-in/ic-27-1-37.5-20","jurisdiction":"us-in","citation":"IC 27-1-37.5-20","heading":"Use of clinical peer when an adverse determination is made or when reviewing or deciding an appeal","body":"Sec. 20. (a) A utilization review entity must ensure that:\n(1) all:\n(A) adverse determinations based on medical necessity are made; and\n(B) appeals are reviewed and decided;\nby a clinical peer; and\n(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:\n(A) responsible for the provision of health care services provided to covered individuals; and\n(B) a physician licensed in Indiana under IC 25-22.5.\n(b) An appeal may not be reviewed or decided by a clinical peer who:\n(1) has a financial interest in the outcome of the appeal; or\n(2) was involved in making the adverse determination that is the subject of the appeal.","path":["TITLE 27. INSURANCE","ARTICLE 1. DEPARTMENT OF INSURANCE","Chapter 37.5. Health Care Service Prior Authorization"],"source_url":"https://iga.in.gov/ic/2026/Title_27.html#27-1-37.5-20","current_through":"2026","vintage":"2026","retrieved_at":"2026-09-25T05:39:04Z","sha256":"ee2389a98645a0ee42fbe666b4eafebb74916af58bbcfc1dae7b91531011d195","source_id":"us-in","stale":false,"prev":"us-in/ic-27-1-37.5-19","next":"us-in/ic-27-1-37.5-21"},"notice":"GroundRules: Original legal text. Not legal advice."}