Ind. Code § 27-1-37.5-13
Unanticipated, medically necessary health care service
Redline — January 1, 2018 → current.View current text →
Current — January 1, 2025
As of January 1, 2018
Sec. 13. (a) This section applies to a claim filed after December 31, 2018, for a medically necessary health care service rendered by a participating provider, the necessity of which:
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 prior authorization is obtained for another health care service; and
(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.
(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;
(c) The health plan:
(1) shall not deny payment for a health care service that is rendered in accordance with:
(A) a prior authorization; and
(B) all terms and conditions of the participating provider's agreement or contract with the health plan; and
(2) may:
(A) require retrospective review of; and
(B) withhold payment for;
an unanticipated health care service described in subsection (a).
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.
Official source: Indiana General Assembly. Reproduced from public-domain Indiana statutes; confirm against the official source for the current text. Not legal advice.