Section 27-1-37.5-13 - Unanticipated, medically necessary health care service; denial; payment for health care service with prior authorization(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:(1) is not anticipated at the time prior authorization is obtained for another health care service; and(2) is determined at the time the other health care service is rendered.(b) The health plan shall not deny a claim described in subsection (a) based solely on lack of prior authorization for the unanticipated health care service.(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).
Added by P.L. 77-2018,SEC. 2, eff. 7/1/2018.