Sec. 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.
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