Indiana § 12-15-11-11 - Requirement to provide certain records; limitations

§ 12-15-11-11. Requirement to provide certain records; limitations

Sec. 11. A provider of services under a home and community based services waiver (as defined in IC 12-8-1.6-2) shall do the following:

(1) Upon request by an individual receiving services under the waiver or the individual's legal guardian, but not more than once per calendar quarter, provide to the individual or the individual's legal guardian the provider's accounting records of service delivery for the recipient.

(2) Upon request, but not more than twice per calendar year, provide to an individual receiving services under the waiver an itemized statement of the services billed by the provider for the recipient. The statement must be in plain language.

As added by P.L.160-2026, SEC.10.

IC 12-15-11.5Chapter 11.5. Lake County Disproportionate Share Hospitals

12-15-11.5-0.5Nonapplicability to certain managed care organizations 12-15-11.5-1"Hospital" 12-15-11.5-2Hospital as contracted provider to eligible individuals 12-15-11.5-3Repealed 12-15-11.5-3.1Repealed 12-15-11.5-4Repealed 12-15-11.5-4.1Repealed 12-15-11.5-4.2Repealed 12-15-11.5-5Repealed 12-15-11.5-6Claim for reimbursement treated as disputed claim 12-15-11.5-7Conclusion of appeal 12-15-11.5-8Dispute resolution procedure requirements 12-15-11.5-9Arbitration process for dispute resolution between hospital and managed care organization 12-15-11.5-10Arbitration of disputed claims

IC 12-15-11.5-0.5Nonapplicability to certain managed care organizations Sec. 0.5. This chapter does not apply to a managed care organization that, on or before July 1, 2000, did not directly contract with a hospital (as defined in section 1 of this chapter) for the provision of services under the office's managed care program.

As added by P.L.141-2001, SEC.1. Amended by P.L.152-2017, SEC.7.

IC 12-15-11.5-1"Hospital" Sec. 1. As used in this chapter, "hospital" refers to an acute care hospital provider that:

(1) is licensed under IC 16-21;

(2) qualifies as a disproportionate share hospital under IC 12-15-16; and

(3) is the sole disproportionate share hospital in a city located in a county having a population of more than four hundred thousand (400,000) and less than seven hundred thousand (700,000).

As added by P.L.142-2000, SEC.2. Amended by P.L.11-2023, SEC.42.

IC 12-15-11.5-2Hospital as contracted provider to eligible individuals Sec. 2. The office's managed care organization shall regard a hospital as a contracted provider in the office's managed care program, which provides a capitated prepayment managed care system, for the provision of medical services to each individual who:

(1) is eligible to receive services under IC 12-15 and has enrolled in the office's managed care services program;

(2) resides in the same city in which the hospital is located; and

(3) has selected a primary care provider who:

(A) is a contracted provider with the office's managed care organization; and

(B) has medical staff privileges at the hospital.

As added by P.L.142-2000, SEC.2. Amended by P.L.141-2001, SEC.2; P.L.152-2017, SEC.8.

IC 12-15-11.5-3RepealedAs added by P.L.142-2000, SEC.2. Amended by P.L.141-2001, SEC.3; P.L.122-2002, SEC.1. Repealed by P.L.145-2005, SEC.30.

IC 12-15-11.5-3.1RepealedAs added by P.L.145-2005, SEC.1. Repealed by P.L.1-2007, SEC.248.

IC 12-15-11.5-4RepealedAs added by P.L.142-2000, SEC.2. Repealed by P.L.1-2002, SEC.172.

IC 12-15-11.5-4.1RepealedAs added by P.L.141-2001, SEC.4. Amended by P.L.122-2002, SEC.2. Repealed by P.L.145-2005, SEC.30.

IC 12-15-11.5-4.2RepealedAs added by P.L.145-2005, SEC.2. Repealed by P.L.1-2007, SEC.248.

IC 12-15-11.5-5RepealedAs added by P.L.142-2000, SEC.2. Repealed by P.L.1-2002, SEC.172.

IC 12-15-11.5-6Claim for reimbursement treated as disputed claim Sec. 6. A claim for reimbursement for services shall be treated as a disputed claim under this chapter if:

(1) it is submitted within one hundred twenty (120) days after the date that services are rendered;

(2) it is denied by the managed care organization;

(3) the hospital submits a written notice of dispute for the claim to the managed care organization not more than sixty (60) days after the receipt of the denial notice;

(4) it is appealed in accordance with the managed care organization's internal appeals process; and

(5) payment for the claim is denied by the managed care organization following its internal appeals process.

As added by P.L.142-2000, SEC.2. Amended by P.L.152-2017, SEC.9.

IC 12-15-11.5-7Conclusion of appeal Sec. 7. The office's managed care organization must conclude an appeal under section 6(4) of this chapter and notify the hospital of its decision not more than thirty-five (35) days after the managed care organization receives a notice from the hospital disputing the managed care organization's denial of a claim.

As added by P.L.142-2000, SEC.2. Amended by P.L.152-2017, SEC.10.

IC 12-15-11.5-8Dispute resolution procedure requirements Sec. 8. (a) A contract entered into by a hospital with the office's managed care organization for the provision of services under the office's managed care program must include a dispute resolution procedure for all disputed claims. Unless agreed to in writing by the hospital and the office's managed care organization, the dispute resolution procedure must include the following requirements:

(1) That submission of disputed claims must be made to an independent arbitrator selected under subsection (b).

(2) Each claim must set forth with specificity the issues to be arbitrated, the amount involved, and the relief sought.

(3) That the hospital and the office's managed care organization shall attempt in good faith to resolve all disputed claims.

(4) The hospital shall submit to the arbitrator any claims that remain in dispute sixty (60) calendar days after the hospital receives written notice as provided under section 7 of this chapter.

(5) That resolution of disputes by the arbitrator must occur not later than ninety (90) calendar days after submission of disputed claims to the arbitrator, unless the parties mutually agree otherwise.

(6) That determinations of the arbitrator are final and binding and not subject to any appeal or review procedure.

(7) That the arbitrator does not have the authority to award any punitive or exemplary damages or to vary or ignore the terms of any contract between the parties and shall be bound by controlling law.

(8) That judgment upon the award rendered by the arbitrator may be entered and enforced in and is subject to the jurisdiction of a court with jurisdiction in Indiana.

(9) That the cost of the arbitrator must be shared equally by the parties, and each party must bear its own attorney and witness fees.

(b) The parties to a contract described in subsection (a) shall mutually agree on an independent arbitrator, or, if the parties are unable to reach agreement on an independent arbitrator, the following procedure must be followed:

(1) Each party shall select an independent representative, and the independent representatives shall select a panel of three (3) independent arbitrators who have experience in institutional and professional health care delivery practices and procedures and have had no prior dealing with either party other than as an arbitrator.

(2) The parties will each strike one (1) arbitrator from the panel selected under subdivision (1), and the remaining arbitrator serves as the arbitrator of the disputed claims under subsection (a).

(3) The procedures for selecting an arbitrator under this section must be completed not later than twenty (20) calendar days after the hospital provides written notice of at least one (1) disputed claim.

As added by P.L.142-2000, SEC.2. Amended by P.L.152-2017, SEC.11.

IC 12-15-11.5-9Arbitration process for dispute resolution between hospital and managed care organization Sec. 9. The arbitration process described in section 8 of this chapter shall also be followed for resolution of disputed claims between a hospital and the office's managed care organization, if the hospital is not a contracted provider in the office's managed health care program.

As added by P.L.142-2000, SEC.2. Amended by P.L.152-2017, SEC.12.

IC 12-15-11.5-10Arbitration of disputed claims Sec. 10. A hospital and the managed care organization of the office shall use the arbitration procedure in section 8 of this chapter for the resolution of all disputed claims that have accrued as of March 17, 2000.

As added by P.L.220-2011, SEC.265. Amended by P.L.152-2017, SEC.13.

IC 12-15-12Chapter 12. Managed Care

12-15-12-0.3"Emergency medical condition" 12-15-12-0.5"Emergency services" 12-15-12-0.7"Post-stabilization care services" 12-15-12-0.9Applicability; Medicaid law controlling over conflicting insurance law 12-15-12-1Providers from whom recipients may obtain services other than physician services; exceptions 12-15-12-2Providers from whom recipients may receive physician services; exceptions 12-15-12-3List of managed care providers furnished recipient; providers included; exception 12-15-12-4Failure by recipient to select managed care provider within reasonable time; assignment by office; exception 12-15-12-4.5Managed care prescription drug program requirements 12-15-12-5Circumstances permitting recipient to receive physician services from provider other than managed care provider; exceptions 12-15-12-6Admission to hospital by physician other than managed care provider; notification of managed care provider; services for which payment made 12-15-12-7Providers from whom recipients may obtain eye care services other than surgical services 12-15-12-8Providers from whom recipients may obtain foot care services 12-15-12-9Providers from whom recipients may obtain psychiatric services 12-15-12-9.5Home modification services; time frame for approval or denial of requests 12-15-12-10Selection or assignment of managed care provider; selection of new provider; exception 12-15-12-11Waiver from Department of Health and Human Services; implementation of chapter 12-15-12-12Payments to providers 12-15-12-13Permitted forms 12-15-12-14Repealed 12-15-12-15Coverage for emergency services 12-15-12-17Coverage for post-stabilization care services 12-15-12-18Payment for emergency services 12-15-12-18.5Reimbursement for emergency medical services provider organizations; implementation 12-15-12-19Repealed 12-15-12-20Child lead poisoning screening 12-15-12-21Accreditation 12-15-12-22Accepting, receiving, and processing electronic claims 12-15-12-23Psychiatrist practicing in community mental health center 12-15-12-24Assessment metrics; transparency and accountability safeguards