Indiana § 27-13-36-12 - Payment to enrollee for service rendered by nonparticipating provider; requirements

§ 27-13-36-12. Payment to enrollee for service rendered by nonparticipating provider; requirements

Sec. 12. (a) As used in this section, "nonparticipating provider" means a provider that has not entered into an agreement with a health maintenance organization to serve as a participating provider.

(b) After September 30, 2009, if a health maintenance organization makes a payment to an enrollee for a health care service rendered by a nonparticipating provider, the health maintenance organization shall include with the payment instrument written notice to the enrollee that includes the following:

(1) A statement specifying the claims covered by the payment instrument.

(2) The name and address of the provider submitting each claim.

(3) The amount paid by the health maintenance organization for each claim.

(4) Any amount of a claim that is the enrollee's responsibility.

(5) A statement in at least 24 point bold type that:

(A) instructs the enrollee to use the payment to pay the nonparticipating provider if the enrollee has not paid the nonparticipating provider in full;

(B) specifies that paying the nonparticipating provider is the enrollee's responsibility; and

(C) states that the failure to make the payment violates the law and may result in collection proceedings or criminal penalties.

As added by P.L.144-2009, SEC.3.

IC 27-13-36.2Chapter 36.2. Provider Payment

27-13-36.2-0.5Applicability 27-13-36.2-1"Clean claim" defined 27-13-36.2-2"Health maintenance organization" defined 27-13-36.2-2.3"Health provider facility" 27-13-36.2-3Notice of deficiencies in claims 27-13-36.2-4Payment or denial of claims; interest 27-13-36.2-4.5Prohibition on altering CPT code for claim; exceptions 27-13-36.2-4.7Prohibition on retroactive rate reduction; notice requirement 27-13-36.2-5Permitted forms 27-13-36.2-6Civil penalties 27-13-36.2-7Repealed 27-13-36.2-8Limitations on recouping, auditing, and correcting payment errors 27-13-36.2-9Claim overpayment adjustment 27-13-36.2-9.5Error in coordination of benefits; submission of claim to appropriate health maintenance organization 27-13-36.2-10Prohibition on denial of claim based on out of network provider referral

IC 27-13-36.2-0.5Applicability Sec. 0.5. Sections 4.7 and 9.5 of this chapter, as added in the 2026 session of the general assembly, and section 8 of this chapter, as amended in the 2026 session of the general assembly, apply to claims submitted under an individual contract and a group contract that:

(1) is entered into, delivered, amended, or renewed after June 30, 2026; and

(2) provides coverage during a plan year beginning after December 31, 2026.

As added by P.L.88-2026, SEC.12.

IC 27-13-36.2-1"Clean claim" defined Sec. 1. As used in this chapter, "clean claim" means a claim submitted by a provider for payment for health care services provided to an enrollee that has no defect, impropriety, or particular circumstance requiring special treatment preventing payment.

As added by P.L.162-2001, SEC.6.

IC 27-13-36.2-2"Health maintenance organization" defined Sec. 2. As used in this chapter, "health maintenance organization" includes:

(1) an insurance administrator that:

(A) collects charges or premiums; and

(B) adjusts or settles claims;

in connection with coverage under a contract with a health maintenance organization; and

(2) a limited service health maintenance organization.

As added by P.L.162-2001, SEC.6.

IC 27-13-36.2-2.3"Health provider facility" Sec. 2.3. As used in this chapter, "health provider facility" has the meaning set forth in IC 27-1-37-3.2.

As added by P.L.88-2026, SEC.13.

IC 27-13-36.2-3Notice of deficiencies in claims Sec. 3. (a) A health maintenance organization shall pay or deny each clean claim in accordance with section 4 of this chapter.

(b) A health maintenance organization shall notify a provider of any deficiencies in a submitted claim not more than:

(1) thirty (30) days for a claim that is filed electronically; or

(2) forty-five (45) days for a claim that is filed on paper;

and describe any remedy necessary to establish a clean claim.

(c) Failure of a health maintenance organization to notify a provider as required under subsection (b) establishes the submitted claim as a clean claim.

As added by P.L.162-2001, SEC.6. Amended by P.L.137-2002, SEC.3.

IC 27-13-36.2-4Payment or denial of claims; interest Sec. 4. (a) A health maintenance organization shall pay or deny each clean claim as follows:

(1) If the claim is filed electronically, not more than thirty (30) days after the date the claim is received by the health maintenance organization.

(2) If the claim is filed on paper, not more than forty-five (45) days after the date the claim is received by the health maintenance organization.

(b) If:

(1) a health maintenance organization fails to pay or deny a clean claim in the time required under subsection (a); and

(2) the health maintenance organization subsequently pays the claim;

the health maintenance organization shall pay the provider that submitted the claim interest on the lesser of the usual, customary, and reasonable charge for the health care services provided to the enrollee or an amount agreed to between the health maintenance organization and the provider paid under this section.

(c) Interest paid under subsection (b):

(1) accrues beginning:

(A) thirty-one (31) days after the date the claim is filed under subsection (a)(1); or

(B) forty-six (46) days after the date the claim is filed under subsection (a)(2); and

(2) stops accruing on the date the claim is paid.

(d) In paying interest under subsection (b), a health maintenance organization shall use the same interest rate as provided in IC 12-15-21-3(7)(A).

As added by P.L.162-2001, SEC.6. Amended by P.L.137-2002, SEC.4.

IC 27-13-36.2-4.5Prohibition on altering CPT code for claim; exceptions Sec. 4.5. (a) A health maintenance organization may not alter the CPT code (as defined in IC 27-1-37.5-3) submitted for a clean claim or pay for a CPT code (as defined in IC 27-1-37.5-3) of lesser monetary value unless:

(1) the CPT code submitted is not in accordance with correct coding guidelines and rules, clinical care guidelines, or the terms and conditions of the participating provider's agreement or contract with the health maintenance organization; or

(2) the medical record of the clean claim has been reviewed by an employee or contractor of the health maintenance organization.

(b) A health maintenance organization may not alter a clean claim to only pay for the CPT codes (as defined in IC 27-1-37.5-3) necessary for an individual's final diagnosis, if the CPT codes (as defined in IC 27-1-37.5-3) billed were deemed medically necessary according to generally accepted clinical care guidelines to reach the final diagnosis.

(c) This section does not prohibit a provider from appealing a claim.

As added by P.L.190-2023, SEC.35.

IC 27-13-36.2-4.7Prohibition on retroactive rate reduction; notice requirement Sec. 4.7. (a) A health maintenance organization may not retroactively reduce the reimbursement rate for any CPT code (as defined in IC 27-1-37.5-3).

(b) A health maintenance organization shall provide at least sixty (60) days notice by:

(1) mail or electronic mail to a provider; and

(2) posting on the health maintenance organization's website;

before prospectively reducing the reimbursement rate for any CPT code (as defined in IC 27-1-37.5-3).

As added by P.L.88-2026, SEC.14.

IC 27-13-36.2-5Permitted forms Sec. 5. A provider shall submit only the following forms for payment by a health maintenance organization:

(1) CMS-1500.

(2) CMS-1450 (UB-04).

(3) American Dental Association (ADA) claim form.

As added by P.L.162-2001, SEC.6. Amended by P.L.208-2018, SEC.32.

IC 27-13-36.2-6Civil penalties Sec. 6. (a) If the commissioner finds that a health maintenance organization has failed during any calendar year to process and pay clean claims in compliance with this chapter, the commissioner may assess an aggregate civil penalty against the health maintenance organization according to the following schedule:

(1) If the health maintenance organization has paid at least eighty-five percent (85%) but less than ninety-five percent (95%) of all clean claims received from all providers during the calendar year in compliance with this chapter, a civil penalty of up to ten thousand dollars ($10,000).

(2) If the health maintenance organization has paid at least sixty percent (60%) but less than eighty-five percent (85%) of all clean claims received from all providers during the calendar year in compliance with this chapter, a civil penalty of at least ten thousand dollars ($10,000) but not more than one hundred thousand dollars ($100,000).

(3) If the health maintenance organization has paid less than sixty percent (60%) of all clean claims received from all providers during the calendar year in compliance with this chapter, a civil penalty of at least one hundred thousand dollars ($100,000) but not more than two hundred thousand dollars ($200,000).

(b) In determining the amount of a civil penalty under this section, the commissioner shall consider whether the health maintenance organization's failure to achieve the standards established by this chapter is due to circumstances beyond the health maintenance organization's control.

(c) A health maintenance organization may contest a civil penalty imposed under this section by requesting an administrative hearing under IC 4-21.5 not more than thirty (30) days after the health maintenance organization receives notice of the assessment of the fine.

(d) If the commissioner imposes a civil penalty under this section, the commissioner may not impose a penalty against the health maintenance organization under IC 27-4-1 for the same activity.

(e) Civil penalties collected under this section shall be deposited in the state general fund.

As added by P.L.162-2001, SEC.6.

IC 27-13-36.2-7RepealedAs added by P.L.178-2003, SEC.88. Repealed by P.L.1-2007, SEC.248.

IC 27-13-36.2-8Limitations on recouping, auditing, and correcting payment errors Sec. 8. (a) A health maintenance organization may not, more than one hundred eighty (180) days after the date on which an overpayment on a provider claim was made to the provider by the health maintenance organization:

(1) request that the provider repay the overpayment; or

(2) adjust a subsequent claim filed by the provider as a method of obtaining reimbursement of the overpayment from the provider.

(b) A health maintenance organization may not recoup a paid claim more than one hundred eighty (180) days after the date on which the claim was initially paid.

(c) A health maintenance organization may not retroactively audit a paid claim more than three (3) years after the date on which the claim was initially paid.

(d) A health maintenance organization may not be required to correct a payment error to a provider if notice of the payment error is not provided within one hundred eighty (180) days after payment for a fully adjudicated claim is received.

(e) Subsections (a), (b), and (d) do not apply in cases of fraud by the provider, the enrollee, or the health maintenance organization with respect to the health benefits claim on which the overpayment or underpayment was made when a final determination of fraud has been made by a court.

(f) Notwithstanding subsections (a) through (d), a health maintenance organization and a hospital licensed under IC 16-21 may enter into a separate written agreement that provides for different time frames than those specified in this section.

As added by P.L.55-2006, SEC.3. Amended by P.L.88-2026, SEC.15.

IC 27-13-36.2-9Claim overpayment adjustment Sec. 9. Every subsequent claim that is adjusted by a health maintenance organization for reimbursement on an overpayment of a previous provider claim made to the provider must be accompanied by an explanation of the reason for the adjustment, including:

(1) an identification of:

(A) the claim on which the overpayment was made; and

(B) if ascertainable, the party financially responsible for the amount overpaid; and

(2) the amount of the overpayment that is being reimbursed to the health maintenance organization through the adjusted subsequent claim.

As added by P.L.55-2006, SEC.4.

IC 27-13-36.2-9.5Error in coordination of benefits; submission of claim to appropriate health maintenance organization Sec. 9.5. (a) If an insurer (as defined in IC 27-8-5.7-3) or a health maintenance organization recoups payment from a provider due to an error in coordination of benefits, the provider may submit a claim for the same services to the appropriate health maintenance organization.

(b) Except as provided in subsection (d) and notwithstanding any other provision of law, a provider may submit a claim to the appropriate health maintenance organization not later than ninety (90) days after the date the recoupment is made.

(c) A provider that submits a claim under this section shall provide documentation to the health maintenance organization demonstrating:

(1) the original submission of the claim to the initial insurer or health maintenance organization; and

(2) the recoupment of payment by the initial insurer or health maintenance organization due to an error in coordination of benefits.

(d) Nothing in this section prevents a health maintenance organization from allowing a provider more time to submit a claim.

As added by P.L.88-2026, SEC.16.

IC 27-13-36.2-10Prohibition on denial of claim based on out of network provider referral Sec. 10. (a) This section applies to an individual contract and a group contract that is entered into, delivered, amended, or renewed after June 30, 2025.

(b) A health maintenance organization may not deny a claim for reimbursement for a covered service or item provided to an enrollee on the sole basis that the referring provider is an out of network provider.

As added by P.L.144-2025, SEC.38 and P.L.215-2025, SEC.65.

IC 27-13-37Chapter 37. Patient Protection; Choice of Health Care Professional

27-13-37-1Enrollees allowed to choose primary care provider from list 27-13-37-2Use of participating provider other than primary care provider 27-13-37-3Continuity of care and referrals when specialty care warranted 27-13-37-4Point-of-service products; dental care services 27-13-37-5Second medical opinions