Use of clinical peer when an adverse determination is made or when reviewing or deciding an appeal
Ind. Code § 27-1-37.5-20
in effectSec. 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.
Source: Open US Law by Vaquill AI (CC BY 4.0)URL: https://iga.in.gov/laws/2026/ic/titles/27Fetched: 10/17/2026