Definitions; Permitted Disclosures by Providers; Coverage of Benefit or Service; Payment of Provider, Application; Provider Credentialing; Provider Directories; Preferred Provider Agreement Prohibitions; Insurer Payment to Insured for Service Rendered by Noncontracted Provider; Requirements; Fully Credentialed Provider Reimbursement; Requirements
See the bold text below:
Section 27-8-11-1. Definitions
Sec. 1. (a) The definitions in this section apply throughout this chapter.
(b) “Credentialing” means a process through which an insurer makes a determination:
(1) based on criteria established by the insurer; and
(2) concerning whether a provider is eligible to:
(A) provide health care services to an insured; and
(B) receive reimbursement for the health care services;
under an agreement entered into between the provider and the insurer under section 3 of this chapter.
(c) “Health care services”:
(1) means health care related services or products rendered or sold by a provider within the scope of the provider’s license or legal authorization; and
(2) includes hospital, medical, surgical, dental, vision, and pharmaceutical services or products.
(d) “Insured” means an individual entitled to reimbursement for expenses of health care services under a policy issued or administered by an insurer.
(e) “Insurer” means an insurance company authorized in this state to issue policies that provide reimbursement for expenses of health care services.
(f) “Person” means an individual, an agency, a political subdivision, a partnership, a corporation, an association, or any other entity.
(g) “Preferred provider plan” means an undertaking to enter into agreements with providers relating to terms and conditions of reimbursements for the health care services of insureds, members, or enrollees relating to the amounts to be charged to insureds, members, or enrollees for health care services.
(h) “Provider” means an individual or entity duly licensed or legally authorized to provide health care services.
Anti-retaliation; Anti-gag clause
Section 27-8-11-4.5. Permitted Disclosures by Providers; Coverage of Benefit or Service; Payment of Provider; Application
Sec. 4.5. (a) An agreement between an insurer and provider under section 3 of this chapter may not prohibit a provider from disclosing:
(1) financial incentives to the provider;
(2) all treatment options available to an insured, including those not covered by the insured’s policy.
(b) An insurer may not penalize a provider financially or in any other manner for making a disclosure permitted under subsection (a).
(c) An insured is not entitled to coverage of a benefit or service under a health insurance policy unless that benefit or service is included in the insured’s health insurance policy.
(d) A provider is not entitled to payment under a policy for benefits or services provided to an insured unless the provider has a contract or an agreement with the insurer.
(e) This section applies to a contract entered, renewed, or modified after June 30, 1996.
Section 27-8-11-7. Provider Credentialing
Sec. 7. (a) This section applies to an insurer that issues or administers a policy that provides coverage for basic health care services (as defined in IC 27-13-1-4).
(b) As used in this section, “clean credentialing application” means an application for network participation that:
(1) is submitted by a provider under this section;
(2) does not contain an error; and
(3) may be processed by the insurer without returning the application to the provider for a revision or clarification.
(c) As used in this section, “credentialing” means a process by which an insurer makes a determination that:
(1) is based on criteria established by the insurer; and
(2) concerns whether a provider is eligible to:
(A) provide health services to an individual eligible for coverage; and
(B) receive reimbursement for the health services;
under an agreement that is entered into between the provider and the insurer.
(d) As used in this section, “unclean credentialing application” means an application for network participation that:
(1) is submitted by a provider under this section;
(2) contains at least one (1) error; and
(3) must be returned to the provider to correct the error.
(e) The department of insurance shall prescribe the credentialing application form used by the Council for Affordable Quality Healthcare (CAQH) in electronic or paper format, which must be used by:
(1) a provider who applies for credentialing by an insurer; and
(2) an insurer that performs credentialing activities.
(f) An insurer shall notify a provider concerning a deficiency on a completed unclean credentialing application form submitted by the provider not later than five (5) business days after the entity
receives the completed unclean credentialing application form. A notice described in this subsection must:
(1) provide a description of the deficiency; and
(2)state the reason why the application was determined to be an unclean credentialing application.
(g) A provider shall respond to the notification required under subsection (f) not later than five (5) business days after receipt of the notice.
(h) An insurer shall notify a provider concerning the status of the provider’s completed clean credentialing application when:
(1) the provider is provisionally credentialed; and
(2) the insurer makes a final credentialing determination concerning the provider.
(i) If the insurer fails to issue a credentialing determination within fifteen (15) days after receiving a completed clean credentialing application form from a provider, the insurer shall provisionally credential the provider in accordance with the standards and guidelines governing provisional credentialing from the National Committee for Quality Assurance or its successor organization. The provisional credentialing license is valid until a determination is made on the credentialing application of the provider.
(j) Once an insurer fully credentials a provider that holds provisional credentialing and a network provider agreement has been executed, then reimbursement payments under the contract shall be paid retroactive to the date the provider was provisionally credentialed. The insurer shall reimburse the provider at the rates determined by the contract between the provider and the insurer.
(k) If an insurer does not fully credential a provider that is provisionally credentialed under subsection (i), the provisional credentialing is terminated on the date the insurer notifies the provider of the adverse credentialing determination. The insurer is not required to reimburse for services rendered while the provider was provisionally credentialed.
This section was amended in 2023 by HB 400 (2023). See https://iga.in.gov/legislative/2023/bills/senate/400
Section 27-8-11-8. Provider Directories
Sec. 8. (a) An insurer may provide to an insured in electronic or paper form a directory of providers with which the insurer has entered into an agreement under section 3 of this chapter.
(b) An insurer that provides a directory described in subsection (a) shall:
(1) inform the insured that the insured may request the directory in paper form; and
(2) provide the directory in paper form upon the request of the insured.
Section 27-8-11-9. Preferred Provider Agreement Prohibitions
Sec. 9. (a) As used in this section, “insurer” includes the following:
(1) An administrator licensed under IC 27-1-25.
(2) A person that pays or administers claims on behalf of an insurer.
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(b) An agreement between an insurer and a provider under this chapter may not contain a provision that:
(1) prohibits, or grants the insurer an option to prohibit, the provider from contracting with another insurer to accept lower payment for health care services than the payment specified in the agreement;
(2) requires, or grants the insurer an option to require, the provider to accept a lower payment from the insurer if the provider agrees with another insurer to accept lower payment for health care services;
(3) requires, or grants the insurer an option of, termination or renegotiation of the agreement if the provider agrees with another insurer to accept lower payment for health care services; or
(4) requires the provider to disclose the provider’s reimbursement rates under contracts with other insurers.
(c) A provision that:
(1) is contained in an agreement between an insurer and a provider under this chapter; and
(2) violates this section;
Section 27-8-11-11. Insurer Payment to Insured for Service Rendered by Noncontracted Provider; Requirements
Sec. 11. (a) As used in this section, “noncontracted provider” means a provider that has not entered into an agreement with an insurer under section 3 of this chapter.
(b) After September 30, 2009, if an insurer makes a payment to an insured for a health care service rendered by a noncontracted provider, the insurer shall include with the payment instrument written notice to the insured 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 insurer for each claim.
(4) Any amount of a claim that is the insured’s responsibility.
(5) A statement in at least 24 point bold type that:
(A) instructs the insured to use the payment to pay the noncontracted provider if the insured has not paid the noncontracted provider in full;
(B) specifies that paying the noncontracted provider is the insured’s responsibility; and
(C) states that the failure to make the payment violates the law and may result in collection proceedings or criminal penalties.
Section 27-8-11-13. Fully Credentialed Provider Reimbursement; Requirements
Sec. 13. (a) A fully credentialed provider shall be reimbursed for eligible services provided at any in-network hospital if the following conditions are met:
(1) The provider submits the documentation required by the insurer to be loaded under the provider group or hospital.
(2) The provider, provider group, or hospital is a network provider with the insurer.
(3) The services are provided in accordance with all terms and conditions of the provider’s, group provider’s, or hospital’s agreement or contract with the insurer.
(4) Prior authorization is obtained in accordance with IC 27-1-37.5 when required by the insurer for an eligible service.
(b) The insurer shall reimburse the provider or hospital for services described in subsection (a) at the rates determined by the contract between the provider and the insurer.
(c) An insurer is not required to credential a provider. However, if:
(1) a provider is employed by a hospital that is part of the hospital’s network that is covered by the insurer; and
(2) the provider meets the insurer’s credentialing requirements;
the insurer shall reimburse the provider for any reimbursable services from the date that the provider was employed by the hospital.
Unless otherwise noted above, these laws can be accessed at https://law.justia.com/codes/indiana/2022/title-27/article-8/chapter-11/