CHAPTER 11. ACCIDENT AND SICKNESS INSURANCE.REIMBURSEMENT AGREEMENTS
IC 27-8-11
Chapter 11. Accident and Sickness Insurance.Reimbursement
Agreements
IC 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.
As added by P.L.140-1984, SEC.1. Amended by P.L.31-1988,
SEC.22; P.L.26-2005, SEC.1.
IC 27-8-11-2
Conflicting provisions
Sec. 2. To the extent of any conflict between this chapter and
IC 27-4-1-4, IC 27-8-5-15, IC 27-8-6-1, or any other statutory
provision, this chapter prevails over the conflicting provision.
Agreements may be entered into under section 3(a)(1) of this chapter
notwithstanding any contradictory policy provision prescribed under
IC 27-8-5-3(a)(9).
As added by P.L.140-1984, SEC.1. Amended by P.L.1-2010,
SEC.111.
IC 27-8-11-3
Reimbursement agreements; immunity
Sec. 3. (a) An insurer may:
(1) enter into agreements with providers relating to terms and
conditions of reimbursement for health care services that may
be rendered to insureds of the insurer, including agreements
relating to the amounts to be charged the insured for services
rendered or the terms and conditions for activities intended to
reduce inappropriate care;
(2) issue or administer policies in this state that include
incentives for the insured to utilize the services of a provider
that has entered into an agreement with the insurer under
subdivision (1); and
(3) issue or administer policies in this state that provide for
reimbursement for expenses of health care services only if the
services have been rendered by a provider that has entered into
an agreement with the insurer under subdivision (1).
(b) Before entering into any agreement under subsection (a)(1), an
insurer shall establish terms and conditions that must be met by
providers wishing to enter into an agreement with the insurer under
subsection (a)(1). These terms and conditions may not discriminate
unreasonably against or among providers. For the purposes of this
subsection, neither differences in prices among hospitals or other
institutional providers produced by a process of individual
negotiation nor price differences among other providers in different
geographical areas or different specialties constitutes unreasonable
discrimination. Upon request by a provider seeking to enter into an
agreement with an insurer under subsection (a)(1), the insurer shall
make available to the provider a written statement of the terms and
conditions that must be met by providers wishing to enter into an
agreement with the insurer under subsection (a)(1).
(c) No hospital, physician, pharmacist, or other provider
designated in IC 27-8-6-1 willing to meet the terms and conditions of
agreements described in this section may be denied the right to enter
into an agreement under subsection (a)(1). When an insurer denies
a provider the right to enter into an agreement with the insurer under
subsection (a)(1) on the grounds that the provider does not satisfy the
terms and conditions established by the insurer for providers entering
into agreements with the insurer, the insurer shall provide the
provider with a written notice that:
(1) explains the basis of the insurer's denial; and
(2) states the specific terms and conditions that the provider, in
the opinion of the insurer, does not satisfy.
(d) In no event may an insurer deny or limit reimbursement to an
insured under this chapter on the grounds that the insured was not
referred to the provider by a person acting on behalf of or under an
agreement with the insurer.
(e) No cause of action shall arise against any person or insurer for:
(1) disclosing information as required by this section; or
(2) the subsequent use of the information by unauthorized
individuals.
Nor shall such a cause of action arise against any person or provider
for furnishing personal or privileged information to an insurer.
However, this subsection provides no immunity for disclosing or
furnishing false information with malice or willful intent to injure
any person, provider, or insurer.
(f) Nothing in this chapter abrogates the privileges and immunities
established in IC 34-30-15 (or IC 34-4-12.6 before its repeal).
As added by P.L.140-1984, SEC.1. Amended by P.L.134-1994,
SEC.1; P.L.191-1996, SEC.1; P.L.1-1998, SEC.151; P.L.1-1999,
SEC.59.
IC 27-8-11-3.1
Repealed
(Repealed by P.L.1-1999, SEC.60.)
IC 27-8-11-4
Accessibility and availability terms; reasonable standards
Sec. 4. Policies issued under section 3(a)(3) or section 3.1 of this
chapter (before its repeal) may not contain terms or conditions that
would operate unreasonably to restrict the access and availability of
health care services for the insured. The commissioner of insurance
may, under IC 4-22-2, adopt rules binding upon insurers prescribing
reasonable standards relating to the accessibility and availability of
health care services for persons insured under policies described in
section 3(a)(3) or section 3.1 of this chapter (before its repeal).
As added by P.L.140-1984, SEC.1. Amended by P.L.134-1994,
SEC.3; P.L.1-1999, SEC.61.
IC 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.
As added by P.L.192-1996, SEC.1.
IC 27-8-11-5
Preferred provider plans; filing sworn statement
Sec. 5. Each person that organizes a preferred provider plan under
this chapter shall file with the commissioner before March 1 of each
year a statement, under oath, upon a form prescribed by the
commissioner that covers the preceding calendar year and includes
the following:
(1) The name and address of each person that has organized a
preferred provider plan.
(2) The names and addresses of the providers with whom the
preferred provider plan has entered into agreements under
section 3 of this chapter.
(3) The geographical area, by counties, within which the
preferred provider plan provides or arranges for health care
services for insureds, members or enrollees.
(4) The number of insureds, members or enrollees covered by
the agreements listed in subdivision (2).
As added by P.L.31-1988, SEC.23.
IC 27-8-11-6
Preferred provider plans; hospital accreditation
Sec. 6. (a) A preferred provider plan may not refuse to enter into
an agreement with a hospital solely because the hospital has not
obtained accreditation from an accreditation organization that:
(1) establishes standards for the organization and operation of
hospitals;
(2) requires the hospital to undergo a survey process for a fee
paid by the hospital; and
(3) was organized and formed in 1951.
(b) This section does not prohibit a preferred provider plan from
using performance indicators or quality standards that:
(1) are developed by private organizations; and
(2) do not rely upon a survey process for a fee charged to the
hospital to evaluate performance.
As added by P.L.259-1995, SEC.2.
IC 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) 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.
(c) An insurer shall notify a provider concerning a deficiency on
a completed credentialing application form submitted by the provider
not later than thirty (30) business days after the insurer receives the
completed credentialing application form.
(d) An insurer shall notify a provider concerning the status of the
provider's completed credentialing application not later than:
(1) sixty (60) days after the insurer receives the completed
credentialing application form; and
(2) every thirty (30) days after the notice is provided under
subdivision (1), until the insurer makes a final credentialing
determination concerning the provider.
As added by P.L.26-2005, SEC.2.
IC 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.
As added by P.L.125-2005, SEC.5.
IC 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.
(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;
is void.
As added by P.L.74-2007, SEC.1.
IC 27-8-11-10
Coverage for dialysis treatment
Sec. 10. (a) As used in this section, "dialysis facility" means an
outpatient facility in Indiana at which a dialysis treatment provider
provides dialysis treatment.
(b) As used in this section, "contracted dialysis facility" means a
dialysis facility that has entered into an agreement with a particular
insurer under section 3 of this chapter.
(c) Notwithstanding section 1 of this chapter, as used in this
section, "insured" refers only to an insured who requires dialysis
treatment.
(d) As used in this section, "insurer" includes the following:
(1) An administrator licensed under IC 27-1-25.
(2) An agent of an insurer.
(e) As used in this section, "non-contracted dialysis facility"
means a dialysis facility that has not entered into an agreement with
a particular insurer under section 3 of this chapter.
(f) An insurer shall not require an insured, as a condition of
coverage or reimbursement, to:
(1) if the nearest dialysis facility is located within thirty (30)
miles of the insured's home, travel more than thirty (30) miles
from the insured's home to obtain dialysis treatment; or
(2) if the nearest dialysis facility is located more than thirty (30)
miles from the insured's home, travel a greater distance than the
distance to the nearest dialysis facility to obtain dialysis
treatment;
regardless of whether the insured chooses to receive dialysis
treatment at a contracted dialysis facility or a non-contracted dialysis
facility.
As added by P.L.111-2008, SEC.4.
IC 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.
As added by P.L.144-2009, SEC.2.