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IC 27-8-5.7-1
"Accident and sickness insurance policy" defined
Sec. 1. As used in this chapter, "accident and sickness insurance
policy" has the meaning set forth in IC 27-8-5-1.
As added by P.L.162-2001, SEC.5.
IC 27-8-5.7-2
"Clean claim" defined
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 by P.L.162-2001, SEC.5.
IC 27-8-5.7-3
"Insurer" defined
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 that:
(A) collects charges or premiums; and
(B) adjusts or settles claims;
in connection with coverage under an accident and sickness
insurance policy.
As added by P.L.162-2001, SEC.5.
IC 27-8-5.7-4
"Provider" defined
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.
IC 27-8-5.7-5
Notice of deficiencies in claims
Sec. 5. (a) An insurer shall pay or deny each clean claim in
accordance with section 6 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) forty-five (45) days for a claim that is filed on paper;
and describe any remedy necessary to establish a clean claim.
(c) Failure of an insurer to notify a provider as required under
subsection (b) establishes the submitted claim as a clean claim.
As added by P.L.162-2001, SEC.5. Amended by P.L.137-2002,
SEC.2.
IC 27-8-5.7-7
Permitted forms
Sec. 7. A provider shall submit only the following forms for
payment by an insurer:
(1) HCFA-1500.
(2) HCFA-1450 (UB-92).
(3) American Dental Association (ADA) claim form.
As added by P.L.162-2001, SEC.5.
IC 27-8-5.7-8
Civil penalties
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 insurer has paid at least eighty-five percent (85%) but
less than ninety-five percent (95%) of all clean claims received
from all providers during the calendar year in compliance with
this chapter, a civil penalty of up to ten thousand dollars
($10,000).
(2) If the insurer has paid at least sixty percent (60%) but less
than eighty-five percent (85%) of all clean claims received from
all providers during the calendar year in compliance with this
chapter, a civil penalty of at least ten thousand dollars ($10,000)
but not more than one hundred thousand dollars ($100,000).
(3) If the insurer has paid less than sixty percent (60%) of all
clean claims received from all providers during the calendar
year in compliance with this chapter, a civil penalty of at least
one hundred thousand dollars ($100,000) but not more than two
hundred thousand dollars ($200,000).
(b) In determining the amount of a civil penalty under this section,
the commissioner shall consider whether the insurer's failure to
achieve the standards established by this chapter is due to
circumstances beyond the insurer's control.
(c) An insurer may contest a civil penalty imposed under this
section by requesting an administrative hearing under IC 4-21.5 not
more than thirty (30) days after the insurer receives notice of the
assessment of the fine.
(d) If the commissioner imposes a civil penalty under this section,
the commissioner may not impose a penalty against the insurer under
IC 27-4-1 for the same activity.
(e) Civil penalties collected under this section shall be deposited
in the state general fund.
As added by P.L.162-2001, SEC.5.
IC 27-8-5.7-9
Repealed
(Repealed by P.L.1-2007, SEC.248.)
IC 27-8-5.7-10
Claim payment errors
Sec. 10. (a) An insurer may not, more than two (2) years after the
date on which an overpayment on a provider claim was made to the
provider by the insurer:
(1) request that the provider repay the overpayment; or
(2) adjust a subsequent claim filed by the provider as a method
of obtaining reimbursement of the overpayment from the
provider.
(b) An insurer may not be required to correct a payment error to
a provider more than two (2) years after the date on which a payment
on a provider claim was made to the provider by the insurer.
(c) This section does not apply in cases of fraud by the provider,
the insured, or the insurer with respect to the claim on which the
overpayment or underpayment was made.
As added by P.L.55-2006, SEC.1.
IC 27-8-5.7-11
Claim overpayment adjustment
Sec. 11. Every subsequent claim that is adjusted by an insurer for
reimbursement on an overpayment of a previous provider claim made
to the provider must be accompanied by an explanation of the reason
for the adjustment, including:
(1) an identification of: