Sec. 7. A claim review agent must satisfy the following minimum requirements:
(1) Provide toll free telephone access at least forty (40) hours each week during normal business hours.
(2) Maintain a telephone call recording system capable of accepting or recording incoming telephone calls or providing instructions during hours other than normal business hours.
(3) Respond to each telephone call left on the recording system maintained under subdivision (2) within two (2) business days after receiving the call.
(4) Protect the confidentiality of the medical records disclosed to the claim review agent.
(5) Include in every notification of a medical review determination based on the appropriateness of health care services delivered to an enrollee the principal reason for the determination.
(6) Ensure that every medical claims review determination based on the appropriateness of health care services delivered to an enrollee is:
(A) made by a provider; or
(B) determined in accordance with standards or guidelines approved by a provider;
who holds a license in the same discipline as the provider who rendered the service.
(7) Include in every notification of a medical review determination based on the appropriateness of the amount charged for a health care service delivered to an enrollee the following:
(A) An explanation of the factual basis for the determination.
(B) If the determination is based on any information from a claims data base, the name and address of the person or entity compiling the data base.
(C) If the determination is based on any information from a claims data base, a statement whether any of the information was obtained from a data base regarding amounts charged for health services performed outside Indiana.
(D) Any percentile limiter applied to determine the appropriateness of an amount charged for a health service provided to an enrollee.
(8) Ensure that every provider referred to in subdivision (6) who makes medical claims review determinations or approves standards or guidelines for medical claims review determinations for the claim review agent has a current license issued by a state licensing agency in the United States.
(9) Develop a medical claims review plan and file a summary of the plan with the department.
As added by P.L.128-1992, SEC.2. Amended by P.L.135-1994, SEC.2.
Copyright ©2024 LegalFix. All rights reserved. LegalFix is not a law firm, is not licensed to practice law, and does not provide legal advice, services, or representation. The information on this website is an overview of the legal plans you can purchase—or that may be provided by your employer as an employee benefit or by your credit union or other membership group as a membership benefit.
LegalFix provides its members with easy access to affordable legal services through a network of independent law firms. LegalFix, its corporate entity, and its officers, directors, employees, agents, and contractors do not provide legal advice, services, or representation—directly or indirectly.
The articles and information on the site are not legal advice and should not be relied upon—they are for information purposes only. You should become a LegalFix member to get legal services from one of our network law firms.
You should not disclose confidential or potentially incriminating information to LegalFix—you should only communicate such information to your network law firm.
The benefits and legal services described in the LegalFix legal plans are not always available in all states or with all plans. See the legal plan Benefit Overview and the more comprehensive legal plan contract during checkout for coverage details in your state.
Use of this website, the purchase of legal plans, and access to the LegalFix networks of law firms are subject to the LegalFix Terms of Service and Privacy Policy.