Title 27, INSURANCE

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 pr…

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…

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 elect…

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 accordanc…

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 …

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) ch…

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.

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.

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 r…

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 re…

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 pub…

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.

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 a…

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.

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 c…

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 s…

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 th…

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 fort…

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 re…

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.

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.

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…

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.

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 opto…

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 c…

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(…

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 accordan…

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.…

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 r…

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…

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…

Sec. 0.1. This chapter applies to an individual contract or a group contract that is entered into, delivered, amended, or renewed after June 30, 2003. As added by P.L.220-2011, SEC.462.

Sec. 1. As used in this chapter, "mail order or Internet based pharmacy" has the meaning set forth in IC 25-26-18-1. As added by P.L.251-2003, SEC.5.

Sec. 2. (a) A health maintenance organization may designate, under an individual contract or a group contract that provides coverage for prescription drugs, a mail order or an Internet based pharmacy to provide prescription drugs to an enrollee. (b) A health maintenance organizat…