CHAPTER 11. ACCIDENT AND SICKNESS INSURANCE.REIMBURSEMENT AGREEMENTS - Indiana Statutes

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.