Sec. 1. (a) Each health maintenance organization shall appoint a medical director who has an unlimited license to practice medicine under IC 25-22.5 or an equivalent license issued by another state.
(b) The medical director is responsible for oversight of treatment policies, protocols, quality assurance activities, and utilization management decisions of the health maintenance organization.
(c) A health maintenance organization shall contract with or employ at least one (1) individual who holds an unlimited license to practice medicine under IC 25-22.5 to do the following:
(1) Develop, in consultation with a group of appropriate providers, the health maintenance organization's treatment policies, protocols, and quality assurance activities.
(2) Consult with the treating provider before an adverse utilization review decision is made.
(d) Compliance with the National Committee on Quality Assurance standards or guidelines is sufficient to meet the requirements of this section.
As added by P.L.69-1998, SEC.14. Amended by P.L.124-2018, SEC.98.
Structure Indiana Code
Article 13. Health Maintenance Organizations
Chapter 36. Patient Protection; Clinical Decision Making; Access to Personnel and Facilities
27-13-36-2. Sufficient Number and Type of Primary Care Providers
27-13-36-2.5. Discrimination on Basis of Provider's License or Certification Prohibited
27-13-36-3. Adequate Number of Services and Providers Within Reasonable Proximity of Subscribers
27-13-36-4. Specialty Areas of Primary Care Providers
27-13-36-5. Referrals to Out of Network Providers
27-13-36-6. Continuation of Care Provisions
27-13-36-7. Telephone Access for Authorization of Care
27-13-36-8. Guidelines for Establishing Reasonable Periods for Appointments
27-13-36-9. Coverage and Reimbursement for Expenses for Care Obtained in an Emergency
27-13-36-11. Standards for Continuity of Care
27-13-36-12. Payment to Enrollee for Service Rendered by Nonparticipating Provider; Requirements