Indiana § 27-7-18-11 - Application; third party access to network; conditions; exception; not required to provide access

§ 27-7-18-11. Application; third party access to network; conditions; exception; not required to provide access

Sec. 11. (a) This section applies if a contracting entity seeks to grant a third party access to:

(1) a provider network contract;

(2) dental services provided pursuant to a provider network contract; or

(3) contractual discounts provided pursuant to a provider network contract.

(b) Except as provided in subsection (c) and section 17 of this chapter, in order for a contracting entity to grant a third party access as described in subsection (a), the following conditions must be satisfied:

(1) When a provider network contract is entered into or renewed, or when there are material modifications to a provider network contract relevant to granting access to a third party as described in subsection (a):

(A) any provider that is a party to the provider network contract must be allowed to choose not to participate in the third party access as described in subsection (a); or

(B) if third party access is to be provided through the acquisition of the provider network by a health insurer, any provider that is a party to the provider network contract must be allowed to enter into a contract directly with the health insurer that acquired the provider network.

(2) The provider network contract must specifically authorize the contracting entity to enter into an agreement with third parties allowing the third parties to obtain the contracting entity's rights and responsibilities as if the third party were the contracting entity.

(3) If the contracting entity seeking to grant a third party access as described in subsection (a) is a dental carrier, a provider that is a party to the provider network contract must have chosen to participate in third party access at the time the provider network contract was entered into or renewed.

(4) If the contracting entity seeking to grant a third party access as described in subsection (a) is a health insurer, the provider network contract must contain a third party access provision specifically granting third party access to the provider network.

(5) If the contracting entity seeking to grant a third party access as described in subsection (a) is a dental carrier, the provider network contract must state that the provider has a right to choose not to participate in the third party access.

(6) The third party being granted access as described in subsection (a) must agree to comply with all of the terms of the provider network contract.

(7) The contracting entity seeking to grant third party access as described in subsection (a) must identify to each provider that is a party to the provider network contract, in writing or electronic form, all third parties in existence as of the date on which the provider network contract is entered into or renewed.

(8) The contracting entity granting third party access as described in subsection (a) must identify, in a list on its website that is updated at least once every ninety (90) days, all third parties to which third party access has been granted.

(9) If third party access as described in subsection (a) is to be granted through the sale or leasing of the network established by the provider network contract, the contracting entity must notify all providers that are parties to the provider network contract of the leasing or sale of the network at least thirty (30) days before the sale or lease of the network takes effect.

(10) The contracting entity seeking to grant third party access to contractual discounts as described in subsection (a)(3) must require each third party to identify the source of the discount on all remittance advices or explanations of payment under which a discount is taken. However, this subdivision does not apply to electronic transactions mandated by the federal Health Insurance Portability and Accountability Act of 1996 (Public Law 104-191).

(c) A contracting entity may grant a third party access as described in subsection (a) even if the conditions set forth in subsection (b)(1) are not satisfied if the contracting entity is not a health insurer or a dental carrier.

(d) Except as provided in subsection (c) and section 17 of this chapter, a provider that is a party to a provider network contract is not required to provide dental services pursuant to third party access granted as described in subsection (a) unless all of the applicable conditions set forth in subsection (b) are satisfied.

As added by P.L.17-2024, SEC.19.