1. (a) A utilization review entity must ensure that:

   1. (1) all:

      1. (A) adverse determinations based on medical necessity are made; and

      2. (B) appeals are reviewed and decided;

         by a clinical peer; and

   2. (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:

      1. (A) responsible for the provision of health care services provided to covered individuals; and
      2. (B) a physician licensed in Indiana under IC 25-22.5 .

2. (b) An appeal may not be reviewed or decided by a clinical peer who:

   1. (1) has a financial interest in the outcome of the appeal; or
   2. (2) was involved in making the adverse determination that is the subject of the appeal.

As added by P.L.144-2025, SEC.29.