Title 27, INSURANCE

Sec. 11.5. (a) If an insurer or a health maintenance organization (as defined in IC 27-13-36.2-2) 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 insurer. (b) Except as provided …

Sec. 12. (a) This section applies to a policy of accident and sickness insurance that is issued, delivered, amended, or renewed after June 30, 2025. (b) An insurer may not deny a claim for reimbursement for a covered service or item provided to an insured on the sole basis that t…

Sec. 2. As used in this chapter, "clean claim" means a claim submitted by a provider for payment under an accident and sickness insurance policy issued in Indiana that has no defect, impropriety, or particular circumstance requiring special treatment preventing payment. As added …

Sec. 2.5. As used in this chapter, "CPT code" refers to the medical billing code that applies to a specific health care service, as published in the Current Procedural Terminology code set maintained by the American Medical Association. As added by P.L.190-2023, SEC.26.

Sec. 2.7. 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.8.

Sec. 3. As used in this chapter, "insurer" means an insurance company issued a certificate of authority in Indiana to issue accident and sickness insurance policies. The term includes: (1) a preferred provider plan (as defined in IC 27-8-11-1); and (2) an insurance administrator …

Sec. 4. As used in this chapter, "provider" has the meaning set forth in IC 27-8-11-1. As added by P.L.162-2001, SEC.5.

Sec. 5. (a) An insurer shall pay or deny each clean claim in accordance with sections 6 and 6.5 of this chapter. (b) An insurer 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) fo…

Sec. 6. (a) An insurer shall pay or deny each clean claim as follows: (1) If the claim is filed electronically, within thirty (30) days after the date the claim is received by the insurer. (2) If the claim is filed on paper, within forty-five (45) days after the date the claim is…

Sec. 6.5. (a) An insurer may not alter the CPT code submitted for a clean claim or pay for a CPT code 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 o…

Sec. 6.7. (a) An insurer may not retroactively reduce the reimbursement rate for any CPT code. (b) An insurer shall provide at least sixty (60) days written notice by: (1) mail or electronic mail to a provider; and (2) posting on the insurer's website; before prospectively implem…

Sec. 7. A provider shall submit only the following forms for payment by an insurer: (1) CMS-1500. (2) CMS-1450 (UB-04). (3) American Dental Association (ADA) claim form. As added by P.L.162-2001, SEC.5. Amended by P.L.208-2018, SEC.10.

Sec. 8. (a) If the commissioner finds that an insurer 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 insurer according to the following schedule: (1) If the in…