Indiana § 27-1-37-11 - Network adequacy standards

§ 27-1-37-11. Network adequacy standards

Sec. 11. The department shall do the following:

(1) Require health carriers to meet network adequacy standards that are no less stringent than the network adequacy standards established by the Centers for Medicare and Medicaid Services.

(2) When assessing whether a health carrier has met the network adequacy standards, consider the availability and variety of independent specialty providers that provide services within in network provider facilities in the health carrier's network.

As added by P.L.215-2025, SEC.52.

IC 27-1-37.1Chapter 37.1. Termination of Health Provider Contracts

27-1-37.1-0.5Application of chapter 27-1-37.1-1"Health maintenance organization" 27-1-37.1-2"Health provider contract" 27-1-37.1-3"Person" 27-1-37.1-4"Provider" 27-1-37.1-5Notice of amendment of contract 27-1-37.1-6Termination of contract without penalty 27-1-37.1-7Effective date of termination 27-1-37.1-8Compliance with proposed amendment not required 27-1-37.1-9Notification to patient that provider's contract terminated 27-1-37.1-10Contrary contract provisions void 27-1-37.1-11Chapter inapplicable to compliance with state or federal laws

IC 27-1-37.1-0.5Application of chapter Sec. 0.5. This chapter does not apply to the termination of a health provider contract under IC 27-1-37-9.

As added by P.L.158-2024, SEC.13.

IC 27-1-37.1-1"Health maintenance organization" Sec. 1. As used in this chapter, "health maintenance organization" means a person that undertakes to provide or arrange for the delivery of health care services to individuals on a prepaid basis, except for the individual's responsibility for copayments or deductibles. The term includes a limited service health maintenance organization. The term does not include a staff-model health maintenance organization that employs a group of providers and that requires the providers to provide health care services solely to individuals who are entitled to coverage under a contract with the staff-model health maintenance organization or an affiliate of the staff-model health maintenance organization.

As added by P.L.196-2001, SEC.1.

IC 27-1-37.1-2"Health provider contract" Sec. 2. As used in this chapter, "health provider contract" means an agreement with a provider relating to terms and conditions of reimbursement for health care services provided to an individual under:

(1) an employee welfare benefit plan (as defined in 29 U.S.C. 1002 et seq.);

(2) a policy of accident and sickness insurance (as defined in IC 27-8-5-1);

(3) a contract with a health maintenance organization;

(4) a self-insurance program established under IC 5-10-8-7(b); or

(5) a prepaid health care delivery plan entered into under IC 5-10-8-7(c).

As added by P.L.196-2001, SEC.1.

IC 27-1-37.1-3"Person" Sec. 3. (a) As used in this chapter, "person" means an individual, an agency, a political subdivision, a partnership, a corporation, an association, or any other entity that enters into a health provider contract with a provider.

(b) The term does not include a health care provider described in IC 16-18-2-163(a)(1), IC 16-18-2-163(a)(2), IC 16-18-2-163(a)(3), or IC 16-18-2-163(a)(4).

As added by P.L.196-2001, SEC.1.

IC 27-1-37.1-4"Provider" Sec. 4. As used in this chapter, "provider" means:

(1) a physician licensed under IC 25-22.5;

(2) a dentist licensed under IC 25-14;

(3) an advanced practice registered nurse licensed under IC 25-23;

(4) a chiropractor licensed under IC 25-10;

(5) a podiatrist licensed under IC 25-29;

(6) an optometrist licensed under IC 25-24; or

(7) a clinical psychologist licensed under IC 25-33.

As added by P.L.196-2001, SEC.1. Amended by P.L.129-2018, SEC.40.

IC 27-1-37.1-5Notice of amendment of contract Sec. 5. A person who enters into a health provider contract with a provider shall provide written notice to the provider of any amendment to the health provider contract not less than forty-five (45) days before the proposed effective date of the amendment.

As added by P.L.196-2001, SEC.1.

IC 27-1-37.1-6Termination of contract without penalty Sec. 6. (a) Subject to subsection (b), a provider who receives notice under section 5 of this chapter may terminate the health provider contract without penalty by informing the person with whom the health care provider contracts that the provider chooses not to approve the amendment.

(b) Notice under subsection (a) must be:

(1) given not later than fifteen (15) days after the provider receives notice under section 5 of this chapter; and

(2) in writing.

As added by P.L.196-2001, SEC.1.

IC 27-1-37.1-7Effective date of termination Sec. 7. The termination of a contract under section 6 of this chapter is effective:

(1) ninety (90) days after the person with whom the provider contracts receives written notice from the provider that the provider does not approve the amendment; or

(2) on a date earlier than the date described in subdivision (1), if agreed to by the person with whom the provider contracts and the provider.

As added by P.L.196-2001, SEC.1.

IC 27-1-37.1-8Compliance with proposed amendment not required Sec. 8. If a person with whom a provider contracts receives notice from a provider under section 6 of this chapter, the person with whom a provider contracts may not require the provider to comply with the proposed amendment.

As added by P.L.196-2001, SEC.1.

IC 27-1-37.1-9Notification to patient that provider's contract terminated Sec. 9. Except in an emergency, a provider who elects to terminate a health provider contract under this section shall, before providing services to a patient who is covered by the contract, notify the patient that the provider's contract has been or will be terminated.

As added by P.L.196-2001, SEC.1.

IC 27-1-37.1-10Contrary contract provisions void Sec. 10. Except as provided in section 7(2) of this chapter, a health provider contract provision that is contrary to this chapter is void.

As added by P.L.196-2001, SEC.1.

IC 27-1-37.1-11Chapter inapplicable to compliance with state or federal laws Sec. 11. This chapter does not apply to an amendment to a health provider contract that is required to comply with a state or federal law.

As added by P.L.196-2001, SEC.1.

IC 27-1-37.2Chapter 37.2. Health Insurance Educator

27-1-37.2-1"Health benefit plan" defined 27-1-37.2-2"Health benefit plan provider" defined 27-1-37.2-3"Health insurance educator" defined 27-1-37.2-4"Position" defined 27-1-37.2-5Establishment of position 27-1-37.2-6Qualifications 27-1-37.2-7Contracts with nonprofit organizations 27-1-37.2-8Duties; prohibitions

IC 27-1-37.2-1"Health benefit plan" defined Sec. 1. As used in this chapter, "health benefit plan" means coverage for health care services provided under:

(1) a policy of accident and sickness insurance (as defined in IC 27-8-5-1);

(2) a contract with a health maintenance organization under IC 27-13; or

(3) any other benefit program that provides payment, reimbursement, or indemnification for the costs of health care except:

(A) worker's compensation or similar insurance; or

(B) benefits provided under a certificate of exemption issued by the worker's compensation board under IC 22-3-2-5.

As added by P.L.258-2001, SEC.1.

IC 27-1-37.2-2"Health benefit plan provider" defined Sec. 2. As used in this chapter, "health benefit plan provider" means a person that provides coverage under a health benefit plan.

As added by P.L.258-2001, SEC.1.

IC 27-1-37.2-3"Health insurance educator" defined Sec. 3. As used in this chapter, "health insurance educator" refers to the health insurance educator appointed under section 6 of this chapter.

As added by P.L.258-2001, SEC.1.

IC 27-1-37.2-4"Position" defined Sec. 4. As used in this chapter, "position" means the position of health insurance educator established under section 5 of this chapter.

As added by P.L.258-2001, SEC.1.

IC 27-1-37.2-5Establishment of position Sec. 5. The department shall establish the position of health insurance educator within the department.

As added by P.L.258-2001, SEC.1.

IC 27-1-37.2-6Qualifications Sec. 6. The commissioner shall appoint a health insurance educator who must possess expertise in the areas of health benefit plans, education, and advocacy.

As added by P.L.258-2001, SEC.1.

IC 27-1-37.2-7Contracts with nonprofit organizations Sec. 7. The department may contract with a nonprofit organization to provide the services required under this chapter.

As added by P.L.258-2001, SEC.1.

IC 27-1-37.2-8Duties; prohibitions Sec. 8. (a) The health insurance educator shall do the following:

(1) Assist health benefit plan consumers in making informed choices regarding health benefit plans by providing information about the following:

(A) The purchase, or enrollment in, a health benefit plan.

(B) The manner in which to resolve a dispute with a health benefit plan.

(C) The method of filing a claim under a health benefit plan.

(D) The availability of resources useful to a health benefit plan consumer.

(E) Consumer rights and responsibilities under a health benefit plan.

(F) Comparative information about health benefit plans to consumers and purchasers of health benefit plans.

(G) Other matters that may further a health benefit plan consumer's knowledge of health insurance benefit plans.

(2) Apply to obtain funds through federal grants and any other source. Any funds obtained shall be used to fulfill the purposes described in subdivision (1).

(b) Notwithstanding subsection (a)(1), the health insurance educator shall not:

(1) recommend a particular company, insurance producer, or product; or

(2) interpret or advise an individual regarding a particular contract or disputed claim that is subject to the federal Employee Retirement Income Security Act (29 U.S.C. 1001 et seq.).

As added by P.L.258-2001, SEC.1.

IC 27-1-37.3Chapter 37.3. Third Party Rights and Responsibilities Under Health Care Contracts

27-1-37.3-0.1Application of chapter 27-1-37.3-1Application of definitions 27-1-37.3-2"Affiliate" 27-1-37.3-3"Contractor" 27-1-37.3-4"Covered individual" 27-1-37.3-5"Health plan" 27-1-37.3-6"Health care contract" 27-1-37.3-7Granting access to contracted health care services; requirements 27-1-37.3-8List of third parties with access to contracted health care services 27-1-37.3-9Identification of contractual source of discounts 27-1-37.3-10Termination of third party rights 27-1-37.3-11Arbitration of disputes

IC 27-1-37.3-0.1Application of chapter Sec. 0.1. The addition of this chapter by P.L.55-2008 applies to a health care contract that is entered into, amended, or renewed after June 30, 2008.

As added by P.L.220-2011, SEC.425.

IC 27-1-37.3-1Application of definitions Sec. 1. Unless otherwise specified in this chapter, the definitions in IC 27-8-11-1 apply throughout this chapter.

As added by P.L.55-2008, SEC.1.

IC 27-1-37.3-2"Affiliate" Sec. 2. As used in this chapter, "affiliate" has the meaning set forth in IC 27-1-25-1.

As added by P.L.55-2008, SEC.1.

IC 27-1-37.3-3"Contractor" Sec. 3. As used in this chapter, "contractor" refers to a person with a primary business purpose of entering into health care contracts with providers.

As added by P.L.55-2008, SEC.1.

IC 27-1-37.3-4"Covered individual" Sec. 4. As used in this chapter, "covered individual" means an individual who is entitled to coverage under a health plan.

As added by P.L.55-2008, SEC.1.

IC 27-1-37.3-5"Health plan" Sec. 5. (a) As used in this chapter, "health plan" means a plan through which coverage is provided for health care services through insurance, prepayment, reimbursement, or otherwise. The term includes the following:

(1) An employee welfare benefit plan (as defined in 29 U.S.C. 1002 et seq.).

(2) A policy of accident and sickness insurance (as defined in IC 27-8-5-1).

(3) An individual contract (as defined in IC 27-13-1-21) or a group contract (as defined in IC 27-13-1-16).

(b) The term does not include the following:

(1) Accident-only, credit, Medicare supplement, long term care, or disability income insurance.

(2) Coverage issued as a supplement to liability insurance.

(3) Worker's compensation or similar insurance.

(4) Automobile medical payment insurance.

(5) A specified disease policy issued as an individual policy.

(6) A short term insurance plan that:

(A) may be renewed for the greater of:

(i) thirty-six (36) months; or

(ii) the maximum period permitted under federal law;

(B) has a term of not more than three hundred sixty-four (364) days; and

(C) has an annual limit of at least two million dollars ($2,000,000).

(7) A policy that provides a stipulated daily, weekly, or monthly payment to an insured during hospital confinement, without regard to the actual expense of the confinement.

As added by P.L.55-2008, SEC.1. Amended by P.L.288-2019, SEC.1.

IC 27-1-37.3-6"Health care contract" Sec. 6. As used in this chapter, "health care contract" means a contract between a person and a provider specifying the rights and responsibilities of the:

(1) person; and

(2) provider;

in relation to payment for and delivery of health care services to a covered individual.

As added by P.L.55-2008, SEC.1.

IC 27-1-37.3-7Granting access to contracted health care services; requirements Sec. 7. A contractor may not lease, rent, or otherwise grant access to a provider's health care services under a health care contract unless the contractor complies with one (1) of the following:

(1) The third party to which the access is granted is:

(A) an employer or another entity providing coverage for health care services to the employer's or entity's employees or members and the entity has a contract with the contractor or the contractor's affiliate for the administration or processing of claims for payment or service provided under the health care contract; or

(B) an affiliate or a subsidiary of the contractor or providing administrative services to or receiving administrative services from the contractor or the contractor's affiliate or subsidiary.

(2) The:

(A) health care contract specifically states that the contractor may lease, rent, or otherwise grant access to the provider's health care services under the health care contract;

(B) third party accessing the health care contract is:

(i) a payer or third party administrator or another entity that administers claims on behalf of the payer;

(ii) a preferred provider organization or preferred provider network, including a physician-hospital organization; or

(iii) an entity engaged in the electronic claims transport between the contractor and the payer; and

(C) third party that is granted access to the provider's health care services under the health care contract is obligated to comply with all the applicable terms of the health care contract.

As added by P.L.55-2008, SEC.1.

IC 27-1-37.3-8List of third parties with access to contracted health care services Sec. 8. (a) A contractor that leases, rents, or otherwise grants access to a provider's health care services as described in section 7(2) of this chapter shall maintain an Internet web page or a toll free telephone number through which the provider may obtain a listing, updated at least semiannually, of the third parties to which access to the provider's health care services has been granted.

(b) A contractor shall, at the time a health care contract is entered into with a provider, identify and provide any preferred provider organization, preferred provider network, physician hospital organization, or other entity identified in section 7(2)(B)(ii) of this chapter that is known at the time of contracting, to which the contractor will grant access to the provider's health care services under section 7 of this chapter.

As added by P.L.55-2008, SEC.1.

IC 27-1-37.3-9Identification of contractual source of discounts Sec. 9. A contractor that leases, rents, or otherwise grants access to a provider's health care services under section 7 of this chapter shall ensure that an explanation of benefits or remittance advice furnished to the provider that delivers health care services under the health care contract identifies the contractual source of any discount that applies.

As added by P.L.55-2008, SEC.1.

IC 27-1-37.3-10Termination of third party rights Sec. 10. Subject to applicable continuity of care requirements, a third party's right to exercise a contractor's rights and responsibilities under a health care contract terminates on the date that the health care contract is terminated.

As added by P.L.55-2008, SEC.1.

IC 27-1-37.3-11Arbitration of disputes Sec. 11. A health care contract may provide for arbitration of disputes arising under this chapter.

As added by P.L.55-2008, SEC.1.

IC 27-1-37.4Chapter 37.4. Electronic Prescription Drug Prior Authorization

27-1-37.4-1"Covered individual" 27-1-37.4-2"Health plan" 27-1-37.4-3"Prior authorization" 27-1-37.4-4Electronic transmission of prior authorization request 27-1-37.4-5Application of chapter 27-1-37.4-6Contradictory contract provisions 27-1-37.4-7Rulemaking 27-1-37.4-8"Step therapy protocol"; notice of denial; required information

IC 27-1-37.4-1"Covered individual" Sec. 1. As used in this chapter, "covered individual" means an individual who is entitled to coverage under a health plan.

As added by P.L.45-2017, SEC.1.

IC 27-1-37.4-2"Health plan" Sec. 2. As used in this chapter, "health plan" means any of the following that provides coverage for prescription drugs:

(1) A policy of accident and sickness insurance (as defined in IC 27-8-5-1).

(2) A contract with a health maintenance organization (as defined in IC 27-13-1-19).

The term includes a person that administers a policy or contract described in subdivision (1) or (2).

As added by P.L.45-2017, SEC.1.

IC 27-1-37.4-3"Prior authorization" Sec. 3. As used in this chapter, "prior authorization" includes a health plan requirement that a prescription drug be authorized for payment by the health plan before the prescription drug is provided to a particular covered individual.

As added by P.L.45-2017, SEC.1.

IC 27-1-37.4-4Electronic transmission of prior authorization request Sec. 4. A health plan shall accept and respond to a request for prior authorization delivered to the health plan by a covered individual's:

(1) prescribing health care provider; or

(2) dispensing pharmacist;

through an electronic transmission that complies with the technical standards developed by the National Council for Prescription Drug Programs for electronic prior authorization transactions (NCPDP SCRIPT).

As added by P.L.45-2017, SEC.1.

IC 27-1-37.4-5Application of chapter Sec. 5. Section 4 of this chapter does not apply if a prescribing health care provider or dispensing pharmacist lacks:

(1) broadband Internet access;

(2) an electronic medical record system; or

(3) a sufficient number of covered individuals as patients or customers, as determined by the commissioner, to warrant the financial expense that compliance with section 4 of this chapter would require.

As added by P.L.45-2017, SEC.1.

IC 27-1-37.4-6Contradictory contract provisions Sec. 6. A contractual provision that:

(1) is contained in a contract that is entered into, amended, or renewed after December 31, 2017; and

(2) contradicts this chapter;

is void.

As added by P.L.45-2017, SEC.1.

IC 27-1-37.4-7Rulemaking Sec. 7. The commissioner may adopt rules under IC 4-22-2 to implement this chapter.

As added by P.L.45-2017, SEC.1.

IC 27-1-37.4-8"Step therapy protocol"; notice of denial; required information Sec. 8. (a) As used in this section, "step therapy protocol" means a protocol that specifies, as a condition of coverage under a health plan, the order in which certain prescription drugs must be used to treat a covered individual's condition.

(b) A health plan that denies prior authorization for a prescription drug described in subdivision (1) or (2) shall provide, in the notice of denial, an alternative list of prescription drugs or alternative treatments as follows:

(1) If:

(A) the prescription drug is not included in the health plan's formulary; and

(B) there is at least one (1) alternative prescription drug in the same therapeutic classification (as defined in IC 12-15-35-17.5);

the alternative list must specify the alternative prescription drugs described in clause (B) that are covered by the health plan.

(2) If the prescription drug is prescribed to treat a condition for which coverage under the health plan requires use of a step therapy protocol, the alternative list must specify the alternative prescription drugs or alternative treatments that are required by the step therapy protocol.

As added by P.L.246-2019, SEC.23 and P.L.264-2019, SEC.12.

IC 27-1-37.5Chapter 37.5. Health Care Service Prior Authorization

27-1-37.5-1Application of chapter 27-1-37.5-1.5"Adverse determination" 27-1-37.5-1.6"Authorization" 27-1-37.5-1.7"Clinical peer" 27-1-37.5-1.8"Clinical criteria" 27-1-37.5-1.9"Cosmetic surgery" 27-1-37.5-2"Covered individual" 27-1-37.5-3"CPT code" 27-1-37.5-3.7"Emergency health care service" 27-1-37.5-3.8"Episode of care" 27-1-37.5-3.9"Health care provider" 27-1-37.5-4"Health care service" 27-1-37.5-5"Health plan" 27-1-37.5-5.4"Medically necessary" 27-1-37.5-6"Participating provider" 27-1-37.5-7"Prior authorization" 27-1-37.5-8Repealed 27-1-37.5-8.1"Urgent health care service" 27-1-37.5-8.3"Utilization review entity" 27-1-37.5-9Repealed 27-1-37.5-10Request for prior authorization; electronic transmission or application programming interface; standardized form 27-1-37.5-11Repealed 27-1-37.5-12Claim for which prior authorization was given; denial; resubmission of claim 27-1-37.5-13Unanticipated, medically necessary health care service 27-1-37.5-13.5Expired 27-1-37.5-13.7Limitations on prior authorization requirements for physical therapy or chiropractic visits 27-1-37.5-14Contrary contract provision void 27-1-37.5-15Violation of chapter 27-1-37.5-16Department of insurance; standardized prior authorization form 27-1-37.5-17Peer to peer review; request 27-1-37.5-19Publishing prior authorization requirements and restrictions and information about prior authorization approvals and denials; implementing new or amending current prior authorization requirements or restrictions; annual report 27-1-37.5-20Use of clinical peer when an adverse determination is made or when reviewing or deciding an appeal 27-1-37.5-21Clinical peer's duty to a covered individual 27-1-37.5-23Request for prior authorization; process 27-1-37.5-24Emergency admission or provision of emergency health care services 27-1-37.5-25Limitation on a utilization review entity's authority to revoke, limit, condition, or restrict an authorization 27-1-37.5-26Authorization periods 27-1-37.5-27Utilization review entity's duty to honor certain authorizations 27-1-37.5-28Automatic authorization for failure to comply with deadlines or requirements

IC 27-1-37.5-1Application of chapter Sec. 1. (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.

(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 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.).

As added by P.L.77-2018, SEC.2. Amended by P.L.190-2023, SEC.13; P.L.144-2025, SEC.2.

IC 27-1-37.5-1.5"Adverse determination" Sec. 1.5. As used in this chapter, "adverse determination" means a 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:

(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.

As added by P.L.190-2023, SEC.14. Amended by P.L.144-2025, SEC.3.

IC 27-1-37.5-1.6"Authorization" 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.

As added by P.L.144-2025, SEC.4.

IC 27-1-37.5-1.7"Clinical peer" Sec. 1.7. As used in this chapter, "clinical peer" means 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 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 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 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.

As added by P.L.190-2023, SEC.15. Amended by P.L.144-2025, SEC.5.

IC 27-1-37.5-1.8"Clinical criteria" Sec. 1.8. As used in this chapter, "clinical criteria" means:

(1) written policies;

(2) written screen procedures;

(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.

As added by P.L.144-2025, SEC.6.

IC 27-1-37.5-1.9"Cosmetic surgery" 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.

As added by P.L.144-2025, SEC.7.

IC 27-1-37.5-2"Covered individual" Sec. 2. As used in this chapter, "covered individual" means an individual who is covered under a health plan. The term includes a covered individual's legally authorized representative.

As added by P.L.77-2018, SEC.2. Amended by P.L.144-2025, SEC.8.

IC 27-1-37.5-3"CPT code" Sec. 3. As used in this chapter, "CPT code" refers to the medical billing code that applies to a specific health care service, as published in the Current Procedural Terminology code set maintained by the American Medical Association.

As added by P.L.77-2018, SEC.2.

IC 27-1-37.5-3.7"Emergency health care service" 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 function; or

(3) result in serious dysfunction of any bodily organ or part of the individual.

As added by P.L.144-2025, SEC.9.

IC 27-1-37.5-3.8"Episode of care" 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.

As added by P.L.144-2025, SEC.10.

IC 27-1-37.5-3.9"Health care provider" 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.

As added by P.L.144-2025, SEC.11.

IC 27-1-37.5-4"Health care service" Sec. 4. (a) As used in this chapter, "health care service" means a health care 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.

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) Cosmetic surgery.

As added by P.L.77-2018, SEC.2. Amended by P.L.144-2025, SEC.12.

IC 27-1-37.5-5"Health plan" Sec. 5. (a) As used in this chapter, "health plan" means any of the following that provides coverage for health care services:

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

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

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

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

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

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

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

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

As added by P.L.77-2018, SEC.2. Amended by P.L.265-2019, SEC.3.

IC 27-1-37.5-5.4"Medically necessary" 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 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.

As added by P.L.144-2025, SEC.13.

IC 27-1-37.5-6"Participating provider" Sec. 6. As used in this chapter, "participating provider" refers to the following:

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

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

As added by P.L.77-2018, SEC.2.

IC 27-1-37.5-7"Prior authorization" Sec. 7. As used in this chapter, "prior authorization" means 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.

As added by P.L.77-2018, SEC.2. Amended by P.L.144-2025, SEC.14.

IC 27-1-37.5-8RepealedAs added by P.L.77-2018, SEC.2. Repealed by P.L.144-2025, SEC.15.

IC 27-1-37.5-8.1"Urgent health care service" 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 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.

As added by P.L.144-2025, SEC.16.

IC 27-1-37.5-8.3"Utilization review entity" 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.

As added by P.L.144-2025, SEC.17.

IC 27-1-37.5-9RepealedAs added by P.L.77-2018, SEC.2. Repealed by P.L.144-2025, SEC.18.

IC 27-1-37.5-10Request for prior authorization; electronic transmission or application programming interface; standardized form Sec. 10. (a) This section does not apply to prior authorization for a prescription drug.

(b) A utilization review entity shall accept a request for prior authorization delivered to the 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 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 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 utilization review entity have entered into an agreement under which the 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 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 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 utilization review entity shall provide for a secure electronic transmission or an application programming interface and 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.

As added by P.L.77-2018, SEC.2. Amended by P.L.208-2018, SEC.8; P.L.144-2025, SEC.19.

IC 27-1-37.5-11RepealedAs added by P.L.77-2018, SEC.2. Amended by P.L.190-2023, SEC.16. Repealed by P.L.144-2025, SEC.20.

IC 27-1-37.5-12Claim for which prior authorization was given; denial; resubmission of claim Sec. 12. (a) This section applies to a claim for a health care service rendered by a health care provider:

(1) for which:

(A) prior authorization is requested after June 30, 2025; and

(B) a utilization review entity gives prior authorization; and

(2) that is rendered in accordance with the authorization.

(b) The utilization review entity shall not deny the claim described in subsection (a) unless:

(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

(6) the patient was not covered under the health plan on the date on which the health care service was rendered.

(c) If:

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

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

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

As added by P.L.77-2018, SEC.2. Amended by P.L.144-2025, SEC.21.

IC 27-1-37.5-13Unanticipated, medically necessary health care service Sec. 13. (a) This section applies to a claim filed after June 30, 2025, for a medically necessary health care service rendered by a health care provider, the necessity of which:

(1) is not anticipated at the time 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.

As added by P.L.77-2018, SEC.2. Amended by P.L.144-2025, SEC.22.

IC 27-1-37.5-13.5ExpiredAs added by P.L.190-2023, SEC.17. Expired 6-30-2026 by P.L.190-2023, SEC.17.

IC 27-1-37.5-13.7Limitations on prior authorization requirements for physical therapy or chiropractic visits 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.

As added by P.L.144-2025, SEC.23.

IC 27-1-37.5-14Contrary contract provision void Sec. 14. A provision that:

(1) is contained in a policy or contract that is entered into, amended, or renewed after June 30, 2025; and

(2) contradicts this chapter;

is void.

As added by P.L.77-2018, SEC.2. Amended by P.L.144-2025, SEC.24.

IC 27-1-37.5-15Violation of chapter Sec. 15. A violation of this chapter by a utilization review entity is an unfair or deceptive act or practice in the business of insurance under IC 27-4-1-4.

As added by P.L.77-2018, SEC.2. Amended by P.L.144-2025, SEC.25.

IC 27-1-37.5-16Department of insurance; standardized prior authorization form Sec. 16. (a) Except as provided in subsection (b), the department shall establish, post, and maintain on the department's website a standardized prior authorization form for use by health care providers and utilization review entities for purposes of any notice or authorization required by a 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 12-7-2.1-218) shall use a standardized prior authorization form prescribed by the office of the secretary of family and social services.

As added by P.L.77-2018, SEC.2. Amended by P.L.265-2019, SEC.4; P.L.144-2025, SEC.26; P.L.145-2026, SEC.142.

IC 27-1-37.5-17Peer to peer review; request 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.

(b) If a utilization review entity makes an adverse determination on a prior authorization request by a covered individual's health care provider, the 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 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 forty-eight (48) hours (excluding weekends and state and federal legal holidays) after the utilization review entity receives the request by the covered individual's health care provider for a peer to peer review if the utilization review entity has received the necessary information for the peer to peer review; and

(2) the 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.

As added by P.L.190-2023, SEC.18. Amended by P.L.144-2025, SEC.27.

IC 27-1-37.5-19Publishing prior authorization requirements and restrictions and information about prior authorization approvals and denials; implementing new or amending current prior authorization requirements or restrictions; annual report 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.

(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.

As added by P.L.144-2025, SEC.28.

IC 27-1-37.5-20Use 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.

As added by P.L.144-2025, SEC.29.

IC 27-1-37.5-21Clinical peer's duty to a covered individual Sec. 21. A clinical peer who:

(1) makes an adverse determination; or

(2) reviews and decides an appeal;

owes a duty to the covered individual to exercise the applicable standard of care.

As added by P.L.144-2025, SEC.30.

IC 27-1-37.5-23Request for prior authorization; process 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 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.

As added by P.L.144-2025, SEC.31.

IC 27-1-37.5-24Emergency admission or provision of emergency health care services 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.

As added by P.L.144-2025, SEC.32.

IC 27-1-37.5-25Limitation on a utilization review entity's authority to revoke, limit, condition, or restrict an authorization 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 received the authorization.

As added by P.L.144-2025, SEC.33.

IC 27-1-37.5-26Authorization periods 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.

As added by P.L.144-2025, SEC.34.

IC 27-1-37.5-27Utilization review entity's duty to honor certain authorizations 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 same health insurance company.

As added by P.L.144-2025, SEC.35.

IC 27-1-37.5-28Automatic authorization for failure to comply with deadlines or requirements 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.

As added by P.L.144-2025, SEC.36.

IC 27-1-37.6Chapter 37.6. Program to Reduce or Eliminate Prior Authorization Requirements for Health Care Providers

27-1-37.6-1"Bundled payments" 27-1-37.6-2"Capitated rate reimbursement arrangement" 27-1-37.6-3"Downside risk" 27-1-37.6-4"Electronic medical record" 27-1-37.6-5"Electronic medical records access agreement" 27-1-37.6-6"Fixed fee schedule" 27-1-37.6-7"Health care provider" 27-1-37.6-8"Health care service" 27-1-37.6-9"Health plan" 27-1-37.6-10"Narrow network" 27-1-37.6-11"Pay for performance arrangement" 27-1-37.6-12"Prior authorization" 27-1-37.6-13"Provider organization" 27-1-37.6-14"Same health care service" 27-1-37.6-15"Value based health care reimbursement agreement" 27-1-37.6-16Program eligibility 27-1-37.6-17Notice of participation requirements 27-1-37.6-18Requiring additional information concerning health care services rendered

IC 27-1-37.6-1"Bundled payments" Sec. 1. As used in this chapter, "bundled payments" means a reimbursement structure in which different health care providers who are treating a patient for the same or related conditions are paid an overall sum for treating a patient's condition rather than being paid for each individual treatment, test, or procedure.

As added by P.L.203-2023, SEC.19.

IC 27-1-37.6-2"Capitated rate reimbursement arrangement" Sec. 2. As used in this chapter, "capitated rate reimbursement arrangement" means a fixed amount of money per patient per unit of time paid in advance to the health care provider for the delivery of health care services.

As added by P.L.203-2023, SEC.19.

IC 27-1-37.6-3"Downside risk" Sec. 3. As used in this chapter, "downside risk" means the risk borne by health care providers in a situation in which, if the total cost of care exceeds projected or budgeted costs, the health care providers will be responsible for a defined percentage of the amount by which the total cost of care exceeds the projected or budgeted costs.

As added by P.L.203-2023, SEC.19.

IC 27-1-37.6-4"Electronic medical record" Sec. 4. As used in this chapter, "electronic medical record":

(1) means a digital collection of medical information about a person that is stored on a computer, electronic platform, or cloud that is automated or permitted to be accessed; and

(2) includes information about a patient's health history, such as:

(A) diagnoses;

(B) medicines;

(C) tests;

(D) allergies; and

(E) treatment plans.

As added by P.L.203-2023, SEC.19.

IC 27-1-37.6-5"Electronic medical records access agreement" Sec. 5. As used in this chapter, "electronic medical records access agreement" means an agreement between a health plan and health care provider that:

(1) authorizes the health plan to access the provider's electronic medical records; or

(2) allows the transfer of automated medical records information between a health care provider and health plan.

As added by P.L.203-2023, SEC.19.

IC 27-1-37.6-6"Fixed fee schedule" Sec. 6. As used in this chapter, "fixed fee schedule" means a total listing of fees used by a health plan to reimburse health care providers or facilities whether:

(1) the fixed fee schedule is based on or equal to Medicare reimbursement for the same health care service; or

(2) the health plan provides the fixed fee schedule to the health care provider.

As added by P.L.203-2023, SEC.19.

IC 27-1-37.6-7"Health care provider" Sec. 7. As used in this chapter, "health care provider" means an individual or entity that is:

(1) licensed, certified, registered, or regulated by an entity described in IC 25-0.5-11;

(2) authorized to provide health care services; and

(3) contracted to provide health care services to members of a health plan.

As added by P.L.203-2023, SEC.19.

IC 27-1-37.6-8"Health care service" Sec. 8. (a) As used in this chapter, "health care service" means a medical or surgical service for the diagnosis, prevention, treatment, cure, or relief of illness, injury, or disease that is measured at the diagnosis and procedure level for an individual health care provider.

(b) The term does not include the following:

(1) Dental services.

(2) Vision services.

(3) Long term rehabilitation treatment.

(4) Pharmaceutical or pharmacist services or products.

As added by P.L.203-2023, SEC.19.

IC 27-1-37.6-9"Health plan" Sec. 9. (a) As used in this chapter, "health plan" means any of the following:

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

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

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

(b) The term includes the following:

(1) The insurer that issues a policy of accident and sickness insurance described in subsection (a)(1).

(2) The health maintenance organization referred to in subsection (a)(2).

(3) The entity with which the state contracts for the administration of the self-insurance program established under IC 5-10-8-7(b) to provide health care coverage.

(c) The term does not include a Medicaid managed care organization, as defined in IC 12-7-2.1-218.

As added by P.L.203-2023, SEC.19. Amended by P.L.145-2026, SEC.143.

IC 27-1-37.6-10"Narrow network" Sec. 10. As used in this chapter, "narrow network" means a network:

(1) significantly limited to select health care providers that offer a range of health care services to health plan members; and

(2) for which any other health care provider that is not included in the network is an out of network health care provider.

As added by P.L.203-2023, SEC.19.

IC 27-1-37.6-11"Pay for performance arrangement" Sec. 11. As used in this chapter, "pay for performance arrangement" means a reimbursement model that reimburses health care providers for meeting predefined targets as defined in the agreement for quality indicators or efficacy parameters to increase the quality or efficacy of care.

As added by P.L.203-2023, SEC.19.

IC 27-1-37.6-12"Prior authorization" Sec. 12. 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.

As added by P.L.203-2023, SEC.19.

IC 27-1-37.6-13"Provider organization" Sec. 13. As used in this chapter, "provider organization" means an entity that serves beneficiaries on a risk basis through a network of employed or affiliated providers.

As added by P.L.203-2023, SEC.19.

IC 27-1-37.6-14"Same health care service" Sec. 14. For the purposes of this chapter, a health care service that is assigned a unique CPT code or combination of CPT codes to be used for the care of a patient with a specific diagnosis is the "same health care service" as another health care service that is assigned the same unique CPT code or combination of CPT codes to be used for the care of a patient with the same specific diagnosis.

As added by P.L.203-2023, SEC.19.

IC 27-1-37.6-15"Value based health care reimbursement agreement" Sec. 15. (a) As used in this chapter, "value based health care reimbursement agreement" may include the following:

(1) An accountable care organization that has a contract with a health plan in which the health plan:

(A) does not assume risk for prior authorization to a provider organization; or

(B) delegates risk to a provider organization to manage prior authorization.

(2) Bundled payments.

(3) A capitated rate reimbursement arrangement.

(4) A pay for performance arrangement.

(5) Any other health care reimbursement arrangement in which the health care provider accepts at most ten percent (10%) of the downside risk.

(b) The term does not include any of the following:

(1) Narrow networks.

(2) Fixed fee schedules.

As added by P.L.203-2023, SEC.19.

IC 27-1-37.6-16Program eligibility Sec. 16. A health care provider that enters into:

(1) a value based health care reimbursement agreement; and

(2) an electronic medical records access agreement;

with a health plan may qualify to participate in a program established by the health plan to reduce or eliminate prior authorization requirements.

As added by P.L.203-2023, SEC.19.

IC 27-1-37.6-17Notice of participation requirements Sec. 17. (a) A health plan shall notify a health care provider of any requirements that a health care provider must meet to participate in a program under section 16 of this chapter.

(b) If a health plan determines that a health care provider is qualified to participate in a program established under section 16 of this chapter, the health plan shall send a notice to the health care provider that contains the following information:

(1) A statement that the health care provider qualifies to participate in the program.

(2) A list of each type of health care service that is subject to the elimination or reduction of prior authorization requirements under the program.

As added by P.L.203-2023, SEC.19.

IC 27-1-37.6-18Requiring additional information concerning health care services rendered Sec. 18. This chapter does not preclude a health plan from requiring a health care provider to provide additional information to the health plan about health care services rendered to the health plan's members.

As added by P.L.203-2023, SEC.19.

IC 27-1-37.7Chapter 37.7. Reporting of Prior Authorization Disputes

27-1-37.7-1"Department" 27-1-37.7-2"Health plan" 27-1-37.7-3"Prior authorization" 27-1-37.7-4Submitting information on prior authorization disputes 27-1-37.7-5Receipt, categorization, and maintenance of information on prior authorization disputes 27-1-37.7-6Confidentiality 27-1-37.7-7Report

IC 27-1-37.7-1"Department" Sec. 1. As used in this chapter, "department" refers to the department of insurance created by IC 27-1-1-1.

As added by P.L.215-2025, SEC.53.

IC 27-1-37.7-2"Health plan" Sec. 2. As used in this chapter, "health plan" has the meaning set forth in IC 27-1-37.5-5.

As added by P.L.215-2025, SEC.53.

IC 27-1-37.7-3"Prior authorization" Sec. 3. As used in this chapter, "prior authorization" has the meaning set forth in IC 27-1-37.5-7.

As added by P.L.215-2025, SEC.53.

IC 27-1-37.7-4Submitting information on prior authorization disputes Sec. 4. A health care provider or health plan may submit information concerning a dispute between a health care provider and a health plan regarding prior authorization to the department.

As added by P.L.215-2025, SEC.53.

IC 27-1-37.7-5Receipt, categorization, and maintenance of information on prior authorization disputes Sec. 5. (a) The department may:

(1) receive;

(2) categorize; and

(3) maintain;

any information provided by a health care provider or a health plan under this chapter.

(b) The department may not adjudicate or otherwise mediate any of the disputes between health care providers and health plans.

As added by P.L.215-2025, SEC.53.

IC 27-1-37.7-6Confidentiality Sec. 6. If the department receives information under section 4 of this chapter from a health care provider or health plan, the department shall keep the following information of the individual who submitted the information confidential:

(1) Name.

(2) Address.

(3) Telephone number.

(4) Electronic mail address.

(5) Personal health information.

(6) Any other information that could identify the individual.

As added by P.L.215-2025, SEC.53.

IC 27-1-37.7-7Report Sec. 7. (a) Before December 1, 2026, the department shall provide a report in an electronic format under IC 5-14-6 to the general assembly with any findings and recommendations related to the information received under section 4 of this chapter.

(b) This section expires July 1, 2027.

As added by P.L.215-2025, SEC.53.

IC 27-1-38Chapter 38. Regulation of Depository Institutions

27-1-38-1"Affiliate" defined 27-1-38-2"Customer" defined 27-1-38-3"Depository institution" defined 27-1-38-4"Insurance producer" defined 27-1-38-5"Person that sells, solicits, advertises, or offers insurance on behalf of a depository institution" defined 27-1-38-6Application of chapter 27-1-38-7Prohibited activities of a depository institution or an affiliate of a depository institution 27-1-38-8Required disclosure concerning insurance related to a loan or a credit extension 27-1-38-9Required disclosures before sale of insurance 27-1-38-10Acknowledgment of receipt of required disclosure 27-1-38-11Requirements for electronic disclosure 27-1-38-12Commissioner examination and investigation 27-1-38-13Allowed activities 27-1-38-14Violation of chapter