IndianaSB 480First Regular Session 124th General Assembly (2025)SenateWALLET

Prior authorization.

Sponsored By: Tyler Johnson (Republican)

Signed by Governor

Summary

Sets forth requirements for a utilization review entity that requires prior authorization of a health care service. Prohibits a utilization review entity from requiring prior authorization for the first 12 physical therapy or chiropractic visits of each new episode of care. Provides that a claim for reimbursement for a covered service or item provided to an insured or enrollee may not be denied on the sole basis that the referring provider is an out of network provider. Repeals superseded provisions regarding prior authorization. Makes corresponding changes.

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Bill Overview

Analyzed Economic Effects

8 provisions identified: 7 benefits, 1 costs, 0 mixed.

Faster care decisions and patient appeals

Beginning July 1, 2025, reviewers must answer urgent care approval requests within 24 hours and other care or drug requests within 48 hours. Weekends and state and federal holidays do not count. Decisions denying, reducing, or ending coverage for medical need, effectiveness, care setting, or experimental status fall under these protections. Denials must explain specific reasons and suggest alternatives. Providers have 48 hours to correct typing, clerical, or spelling errors, accept an alternative, or notify reviewers of an appeal; reviewers then have 48 hours to respond. Reviewers must also offer peer-to-peer review and, once needed information arrives, make every effort to hold it within 48 hours, excluding those same days.

Stronger emergency coverage for insured patients

Beginning July 1, 2025, reviewers must cover emergency services needed to screen and stabilize covered patients. Patients or providers get at least 24 hours after emergency admission or service to give notice. A provider’s written certification within 72 hours after admission creates a presumption that emergency care was medically needed. Weekends and state and federal holidays do not count toward either period; overturning that presumption requires clear and convincing evidence. Medical need cannot depend on network status, and out-of-network emergency providers cannot face stricter coverage or reimbursement limits.

Broader patient rights with insurance enforcement

Beginning July 1, 2025, the law covers more approval reviewers, including those working for employers, health plans, and preferred provider organizations. It also reaches reviewers for other organizations providing or managing covered health benefits and requires self-insured public employer programs established under IC 5-10-8-7(b) to follow applicable approval rules. Legally authorized representatives can use these rights on patients’ behalf. Conflicting insurance terms are void in policies or contracts entered into, amended, or renewed after June 30, 2025. Reviewers’ violations count as unfair or deceptive insurance practices.

Clearer approval rules and request tracking

Beginning July 1, 2025, providers must send non-drug approval requests securely online or through a software connection; reviewers must accept them and issue tracking codes. Written agreements allow non-electronic requests using the state’s standard form for financial hardship, poor internet access, or too few patients to justify costs. Reviewers must make current approval rules, restrictions, and clinical criteria easy to find and understand. Before new or changed requirements take effect, reviewers must update their websites and give patients and providers at least 60 days’ written notice. They must post approval and denial statistics by specialty, service or drug, medical reason, denial reason, appeals, and timing, and report annually to Indiana’s insurance department by December 31.

Fewer coverage reversals for patient care

Beginning July 1, 2025, reviewers cannot revoke, limit, or add conditions to approvals when care starts within 45 days of provider receipt. Weekends and state and federal holidays do not count toward those 45 days. For approvals requested after June 30, 2025, claims matching the approval can be denied only for listed reasons. These include intentional material misrepresentation to obtain unlawful payment, lost service coverage or provider contract, late filing, no reviewer liability, or no patient coverage on the service date; providers can correct unintentional information mismatches and resubmit. Reviewers also cannot demand review after care or deny payment solely for missing approval when unexpected, medically necessary care arises during approved care—or care needing no approval—and the provider documents the need.

Patients get twelve approval-free therapy visits

Beginning July 1, 2025, reviewers cannot require prior approval for the first 12 physical therapy visits in each new episode. The same protection covers the first 12 chiropractic visits in each new episode of care. This approval exemption does not apply to Medicaid or state employee health plans.

Qualified clinical reviewers protect patient care

Beginning July 1, 2025, clinical peers must decide medical-need denials and appeals under an Indiana-licensed physician’s clinical direction. Physician reviewers generally must match the requesting physician’s specialty and, when applicable, subspecialty. Primary care reviewers need matching general-practice certification and at least three years of general medicine practice. Advanced practice nurse reviewers need a similar patient population focus and role specialty; reviewers must meet applicable licensing, reciprocity, or interstate compact rules. Appeal reviewers cannot have a financial stake or have joined the original decision, and clinical peers owe patients the applicable standard of care.

Some Medicaid services lack approval protections

Beginning July 1, 2025, the prior approval chapter excludes services under Indiana’s Pathways for Aging and Health and Wellness Medicaid waivers. It also excludes the named step-therapy exception procedures under IC 5-10-8-17, IC 27-8-5-30, and IC 27-13-7-23. The chapter does not apply where federal Medicaid law or rules override it. Patients do not receive this chapter’s protections for those excluded services or procedures.

Sponsors & Cosponsors

Sponsor

  • Tyler Johnson

    Republican • Senate

Cosponsors

  • Andrea Hunley

    Democratic • Senate

  • Andy Zay

    Affiliation unavailable

  • Blake Doriot

    Republican • Senate

  • Brad Barrett

    Republican • House

  • Brett Clark

    Republican • Senate

  • Brian Buchanan

    Republican • Senate

  • Cyndi Carrasco

    Republican • Senate

  • Dan Dernulc

    Republican • Senate

  • Daryl Schmitt

    Republican • Senate

  • David Niezgodski

    Democratic • Senate

  • Ed Charbonneau

    Republican • Senate

  • Eric Bassler

    Republican • Senate

  • Eric Koch

    Republican • Senate

  • Fady Qaddoura

    Democratic • Senate

  • Gary Byrne

    Republican • Senate

  • Greg Taylor

    Democratic • Senate

  • Greg Walker

    Republican • Senate

  • J.D. Ford

    Democratic • Senate

  • James Buck

    Republican • Senate

  • James Tomes

    Republican • Senate

  • Jean Leising

    Republican • Senate

  • Jeff Raatz

    Republican • Senate

  • Joanna King

    Republican • House

  • Julie McGuire

    Republican • House

  • Justin Busch

    Republican • Senate

  • Kyle Walker

    Republican • Senate

  • La Keisha Jackson

    Democratic • Senate

  • Linda Rogers

    Republican • Senate

  • Liz Brown

    Republican • Senate

  • Lonnie Randolph

    Democratic • Senate

  • Mark Spencer

    Democratic • Senate

  • Martin Carbaugh

    Republican • House

  • Michael Crider

    Republican • Senate

  • Michael Young

    Republican • Senate

  • Mike Bohacek

    Republican • Senate

  • Randy Maxwell

    Republican • Senate

  • Rick Niemeyer

    Republican • Senate

  • Rodney Pol

    Democratic • Senate

  • Ron Alting

    Republican • Senate

  • Scott Alexander

    Republican • Senate

  • Shelli Yoder

    Democratic • Senate

  • Spencer Deery

    Republican • Senate

  • Stacey Donato

    Republican • Senate

  • Susan Glick

    Republican • Senate

  • Travis Holdman

    Republican • Senate

  • Vaneta Becker

    Republican • Senate

Roll Call Votes

All Roll Calls

Yes: 180 • No: 4

Senate vote • 4/16/2025

Senate concurred with House amendments

Yes: 39 • No: 2

House vote • 4/14/2025

Third reading: passed

Yes: 94 • No: 0

Senate vote • 2/20/2025

Third reading: passed

Yes: 47 • No: 2

Actions Timeline

  1. Signed by the Governor

    5/1/2025Senate
  2. Public Law 144

    5/1/2025Senate
  3. Signed by the President of the Senate

    4/23/2025Senate
  4. Signed by the Speaker

    4/22/2025House
  5. Signed by the President Pro Tempore

    4/17/2025Senate
  6. Senate concurred with House amendments; Roll Call 466: yeas 39, nays 2

    4/16/2025Senate
  7. Motion to concur filed

    4/15/2025Senate
  8. Returned to the Senate with amendments

    4/15/2025House
  9. Third reading: passed; Roll Call 443: yeas 94, nays 0

    4/14/2025House
  10. Amendment #1 (Barrett) prevailed; voice vote

    4/10/2025House
  11. Amendment #2 (Mayfield) prevailed; voice vote

    4/10/2025House
  12. Second reading: amended, ordered engrossed

    4/10/2025House
  13. Committee report: amend do pass, adopted

    4/8/2025House
  14. First reading: referred to Committee on Insurance

    3/3/2025House
  15. Referred to the House

    2/21/2025Senate
  16. House sponsor: Representative Barrett

    2/20/2025Senate
  17. Cosponsors: Representatives Carbaugh, McGuire, King

    2/20/2025Senate
  18. Third reading: passed; Roll Call 203: yeas 47, nays 2

    2/20/2025Senate
  19. Second reading: ordered engrossed

    2/17/2025Senate
  20. Committee report: amend do pass, adopted

    2/13/2025Senate
  21. Senator Young M added as coauthor

    2/3/2025Senate
  22. Senator Carrasco added as coauthor

    2/3/2025Senate
  23. Senator Schmitt added as coauthor

    2/3/2025Senate
  24. Senators Raatz, Spencer, Taylor G, Walker G added as coauthors

    1/30/2025Senate
  25. Senator Tomes added as coauthor

    1/30/2025Senate

Bill Text

  • Engrossed Senate Bill (S)

  • Enrolled Senate Bill (S)

  • Introduced Senate Bill (S)

  • Senate Bill (H)

  • Senate Bill (S)

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