reglab/housing_qa huggingface dataset:
IN Code § 27-13-36.2-6 (2021)
2021 Indiana Code|Title 27. Insurance|Article 13. Health Maintenance Organizations|Chapter 36.2. Provider Payment|27-13-36.2-6. Civil Penalties

Sec. 6. (a) If the commissioner finds that a health maintenance organization 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 health maintenance organization according to the following schedule:(1) If the health maintenance organization 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 health maintenance organization 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 health maintenance organization 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 health maintenance organization's failure to achieve the standards established by this chapter is due to circumstances beyond the health maintenance organization's control.(c) A health maintenance organization 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 health maintenance organization 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 health maintenance organization 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.6.
IN Code § 27-13-36.2-8 (2021)
2021 Indiana Code|Title 27. Insurance|Article 13. Health Maintenance Organizations|Chapter 36.2. Provider Payment|27-13-36.2-8. Claim Payment Errors

Sec. 8. (a) A health maintenance organization 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 health maintenance organization:(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) A health maintenance organization 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 health maintenance organization.(c) This section does not apply in cases of fraud by the provider, the enrollee, or the health maintenance organization with respect to the claim on which the overpayment or underpayment was made.As added by P.L.55-2006, SEC.3.
IN Code § 27-13-36.2-9 (2021)
2021 Indiana Code|Title 27. Insurance|Article 13. Health Maintenance Organizations|Chapter 36.2. Provider Payment|27-13-36.2-9. Claim Overpayment Adjustment

Sec. 9. Every subsequent claim that is adjusted by a health maintenance organization 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:(A) the claim on which the overpayment was made; and(B) if ascertainable, the party financially responsible for the amount overpaid; and(2) the amount of the overpayment that is being reimbursed to the health maintenance organization through the adjusted subsequent claim.As added by P.L.55-2006, SEC.4.
IN Code § 27-13-37-1 (2021)
2021 Indiana Code|Title 27. Insurance|Article 13. Health Maintenance Organizations|Chapter 37. Patient Protection; Choice of Health Care Professional|27-13-37-1. Enrollees Allowed to Choose Primary Care Provider From List

Sec. 1. (a) A health maintenance organization shall allow each enrollee of the health maintenance organization to choose the enrollee's own primary care provider from a list of participating primary care providers within the health maintenance organization.(b) The list described in subsection (a) shall be updated semiannually and must include a sufficient number of primary care providers that accept new enrollees. The list must be:(1) provided to each enrollee annually; and(2) sent to an enrollee at the enrollee's request.As added by P.L.69-1998, SEC.15.
IN Code § 27-13-37-2 (2021)
2021 Indiana Code|Title 27. Insurance|Article 13. Health Maintenance Organizations|Chapter 37. Patient Protection; Choice of Health Care Professional|27-13-37-2. Use of Participating Provider Other Than Primary Care Provider

Sec. 2. (a) Each health maintenance organization shall develop a system to allow an enrollee to use an appropriate participating provider to manage the enrollee's medical condition when the enrollee's primary care provider determines that the use of another appropriate participating provider is warranted by the enrollee's medical condition.(b) A primary care provider who makes the required determination under subsection (a) shall refer the enrollee to a participating provider whom the primary care provider determines is appropriate.(c) A health maintenance organization shall provide coverage under this section for treatment received by an enrollee from an appropriate participating provider when the enrollee is referred to the participating provider as provided in this section for as long as the treatment is appropriate for the medical condition, subject to the terms and conditions of the enrollee's contract with the health maintenance organization.(d) A contract between a health maintenance organization and a primary care provider may not provide for a financial or other penalty to the primary care provider for making a referral allowed under this section.As added by P.L.69-1998, SEC.15.
IN Code § 27-13-37-3 (2021)
2021 Indiana Code|Title 27. Insurance|Article 13. Health Maintenance Organizations|Chapter 37. Patient Protection; Choice of Health Care Professional|27-13-37-3. Continuity of Care and Referrals When Specialty Care Warranted

Sec. 3. Beginning July 1, 1999, each health maintenance organization shall provide continuity of care and referral to appropriate participating providers when specialty care is warranted, including the following:(1) Enrollees have access to appropriate participating providers on a timely basis.(2) Enrollees have a choice of appropriate participating providers when a referral is made.As added by P.L.69-1998, SEC.15.
IN Code § 27-13-37-4 (2021)
2021 Indiana Code|Title 27. Insurance|Article 13. Health Maintenance Organizations|Chapter 37. Patient Protection; Choice of Health Care Professional|27-13-37-4. Point-of-Service Products; Dental Care Services

Sec. 4. (a) Each health maintenance organization shall offer to each purchaser of a group contract or individual contract a point-of-service product to the extent permitted by IC 27-13-13-8.(b) Beginning July 1, 2001, a limited service health maintenance organization that provides dental care services shall offer to each purchaser of a group contract or individual contract:(1) a point-of-service product to the extent permitted by IC 27-13-34-10(a)(6);(2) a preferred provider plan (as defined in IC 27-8-11-1); or(3) a policy of accident and sickness insurance (as defined in IC 27-8-5-1);that provides dental care services.As added by P.L.69-1998, SEC.15. Amended by P.L.91-2000, SEC.3.
IN Code § 27-13-37-5 (2021)
2021 Indiana Code|Title 27. Insurance|Article 13. Health Maintenance Organizations|Chapter 37. Patient Protection; Choice of Health Care Professional|27-13-37-5. Second Medical Opinions

Sec. 5. Each health maintenance organization shall allow an enrollee who has received a medical opinion from a participating provider to obtain a second medical opinion from an appropriate participating provider concerning the enrollee's medical condition at the enrollee's request.As added by P.L.69-1998, SEC.15.
IN Code § 27-13-37.5-0.1 (2021)
2021 Indiana Code|Title 27. Insurance|Article 13. Health Maintenance Organizations|Chapter 37.5. Mail Order and Internet Pharmacy Designation|27-13-37.5-0.1. Application of Chapter

Sec. 0.1. This chapter applies to an individual contract or a group contract that is entered into, delivered, amended, or renewed after June 30, 2003.As added by P.L.220-2011, SEC.462.
IN Code § 27-13-37.5-1 (2021)
2021 Indiana Code|Title 27. Insurance|Article 13. Health Maintenance Organizations|Chapter 37.5. Mail Order and Internet Pharmacy Designation|27-13-37.5-1. "Mail Order or Internet Based Pharmacy"

Sec. 1. As used in this chapter, "mail order or Internet based pharmacy" has the meaning set forth in IC 25-26-18-1.As added by P.L.251-2003, SEC.5.
IN Code § 27-13-37.5-2 (2021)
2021 Indiana Code|Title 27. Insurance|Article 13. Health Maintenance Organizations|Chapter 37.5. Mail Order and Internet Pharmacy Designation|27-13-37.5-2. Designation of Mail Order or Internet Based Pharmacy

Sec. 2. (a) A health maintenance organization may designate, under an individual contract or a group contract that provides coverage for prescription drugs, a mail order or an Internet based pharmacy to provide prescription drugs to an enrollee.(b) A health maintenance organization may not require an enrollee to obtain a prescription drug from a pharmacy designated under subsection (a) as a condition of coverage.As added by P.L.251-2003, SEC.5.
IN Code § 27-13-38-1 (2021)
2021 Indiana Code|Title 27. Insurance|Article 13. Health Maintenance Organizations|Chapter 38. Patient Protection; Drugs and Devices; Drug Utilization Review Program|27-13-38-1. Drug and Devices Formularies

Sec. 1. (a) A health maintenance organization may apply a formulary to the prescription drug and devices benefits provided by the health maintenance organization if the formulary is developed, reviewed, and updated:(1) in consultation with; and(2) with the approval of;a pharmacy and therapeutics committee, a majority of whose members are licensed physicians.(b) If a health maintenance organization maintains one (1) or more drug and devices formularies, the health maintenance organization shall do the following:(1) Disseminate to participating providers and pharmacists the complete drug and devices formulary or formularies maintained by the health maintenance organization, including a list of the devices and prescription drugs on the formulary by major therapeutic category that specifies whether a particular drug or device is preferred over other drugs or devices.(2) Establish and maintain an expeditious process or procedure that allows an enrollee to obtain, without penalty or additional cost sharing beyond that provided for in the enrollee's covered benefits with the health maintenance organization, coverage for a specific, medically necessary and appropriate nonformulary drug or device without prior approval from the health maintenance organization.(c) A health maintenance organization may not:(1) void a contract; or(2) refuse to renew a contract;between the health maintenance organization and a prescribing provider because the prescribing provider has prescribed a medically necessary and appropriate nonformulary drug or device as provided in subsection (b)(2).As added by P.L.69-1998, SEC.16.
IN Code § 27-13-38-2 (2021)
2021 Indiana Code|Title 27. Insurance|Article 13. Health Maintenance Organizations|Chapter 38. Patient Protection; Drugs and Devices; Drug Utilization Review Program|27-13-38-2. Substitution of Brand Name Drugs

Sec. 2. Subject to IC 16-42-22:(1) a pharmacist shall not substitute; and(2) a health maintenance organization shall not require the substitution of;a different single source brand name drug for a single source brand name drug written on a prescription form or electronically transmitted to a pharmacy unless the substitution is approved by the prescribing provider.As added by P.L.69-1998, SEC.16. Amended by P.L.204-2005, SEC.20.
IN Code § 27-13-38-3 (2021)
2021 Indiana Code|Title 27. Insurance|Article 13. Health Maintenance Organizations|Chapter 38. Patient Protection; Drugs and Devices; Drug Utilization Review Program|27-13-38-3. Drug Utilization Review Programs; Contents

Sec. 3. Each health maintenance organization that has a prescription drug benefit shall establish and operate, or cause to be established and operated, a drug utilization review program that includes the following:(1) Retrospective review of prescription drugs furnished to enrollees.(2) Education of physicians, enrollees, and pharmacists regarding the appropriate use of prescription drugs.(3) Ongoing periodic examination of data on outpatient prescription drugs to ensure quality therapeutic outcomes for enrollees.(4) Clinically relevant criteria and standards for drug therapy.(5) Nonproprietary criteria and standards, developed and revised through an open, professional consensus process.(6) Interventions that focus on improving therapeutic outcomes, including prospective drug utilization review programs that monitor for possible prescription drug problems or complications, including drug to disease interactions, drug to drug interactions, or therapeutic duplication.As added by P.L.69-1998, SEC.16.
IN Code § 27-13-38-4 (2021)
2021 Indiana Code|Title 27. Insurance|Article 13. Health Maintenance Organizations|Chapter 38. Patient Protection; Drugs and Devices; Drug Utilization Review Program|27-13-38-4. Drug Utilization Review Programs; Primary Emphasis

Sec. 4. The primary emphasis of the drug utilization review program established under section 3 of this chapter is to enhance quality of care for enrollees by assuring appropriate drug therapy.As added by P.L.69-1998, SEC.16.
IN Code § 27-13-38-5 (2021)
2021 Indiana Code|Title 27. Insurance|Article 13. Health Maintenance Organizations|Chapter 38. Patient Protection; Drugs and Devices; Drug Utilization Review Program|27-13-38-5. Drug Utilization Review Programs; Confidentiality of Enrollees

Sec. 5. The name of an enrollee that is discovered in the course of the drug utilization review program shall remain confidential.As added by P.L.69-1998, SEC.16.
IN Code § 27-13-38-6 (2021)
2021 Indiana Code|Title 27. Insurance|Article 13. Health Maintenance Organizations|Chapter 38. Patient Protection; Drugs and Devices; Drug Utilization Review Program|27-13-38-6. Adoption of Rules

Sec. 6. The commissioner, with input and assistance from the state health commissioner, may adopt rules under IC 4-22-2 to implement this chapter.As added by P.L.69-1998, SEC.16.
IN Code § 27-13-38-7 (2021)
2021 Indiana Code|Title 27. Insurance|Article 13. Health Maintenance Organizations|Chapter 38. Patient Protection; Drugs and Devices; Drug Utilization Review Program|27-13-38-7. Prescription Drug Coverage

Sec. 7. (a) The definitions in IC 27-13-7-23 apply throughout this section.(b) A health maintenance organization shall not remove a prescription drug from the health maintenance organization's formulary, change the cost sharing requirements that apply to a prescription drug, or change the utilization review program requirements that apply to a prescription drug unless that health maintenance organization does at least one (1) of the following:(1) At least sixty (60) days before the removal or change is effective, send written notice of the removal or change to each enrollee for whom the prescription drug has been prescribed during the preceding twelve (12) month period.(2) At the time an enrollee for whom the prescription drug has been prescribed during the preceding twelve (12) month period requests a refill of the prescription drug, provide to the enrollee:(A) written notice of the removal or change; and(B) a sixty (60) day supply of the prescription drug under the terms that applied before the removal or change.As added by P.L.19-2016, SEC.6.
IN Code § 27-13-38-8 (2021)
2021 Indiana Code|Title 27. Insurance|Article 13. Health Maintenance Organizations|Chapter 38. Patient Protection; Drugs and Devices; Drug Utilization Review Program|27-13-38-8. Application; Definitions; Denial of Coverage to Synchronize Prohibited; Coverage of Synchronization

Sec. 8. (a) This section does not apply to a mail order pharmacy or to specialty drugs.(b) This section applies to an individual contract or a group contract that provides coverage for prescription medications.(c) As used in this section, "synchronize" means to use a single pharmacy dispensing process as a means of coordinating the enrollee's medications at the same time when:(1) a particular medication:(A) is of a formulation that can be effectively split; and(B) does not have quantity limits or dose optimization criteria as specified in the individual or group contract's formulary and prior authorization requirements;(2) the enrollee is on a stabilized treatment plan for a chronic condition and the synchronization is for those drugs treating a chronic condition; and(3) the medication is not:(A) an opioid, stimulant, sedative, or hypnotic medication; or(B) another medication that is addictive and subject to abuse.(d) An individual contract or group contract that provides coverage for prescription drugs may not deny coverage for the refill of any drug prescribed for the treatment of a chronic illness that is made in accordance with a plan between the enrollee and a pharmacist to synchronize the refilling of multiple prescriptions for the enrollee.(e) An individual contract or a group contract must provide coverage for a medication that is dispensed in a quantity that allows synchronization of the enrollee's medications in accordance with a plan made between the enrollee and the pharmacy to synchronize the enrollee's medications for chronic conditions.As added by P.L.202-2017, SEC.21.
IN Code § 27-13-39-1 (2021)
2021 Indiana Code|Title 27. Insurance|Article 13. Health Maintenance Organizations|Chapter 39. Patient Protection; Experimental Treatments|27-13-39-1. Procedures Regarding Experimental Treatments

Sec. 1. (a) A health maintenance organization shall develop and implement a procedure to evaluate whether to provide coverage for new medical technologies and new applications of existing medical technologies, including medical treatments, procedures, drugs, and devices.(b) A health maintenance organization shall maintain the procedure required under subsection (a) in writing. The written procedure shall describe the process used to determine whether the health maintenance organization will provide coverage for new medical technologies and new uses of existing medical technologies.(c) The procedure required under this section shall include a review of information from appropriate governmental regulatory bodies and published scientific literature about new medical technologies and new uses of existing medical technologies.(d) A health maintenance organization shall include appropriate professionals in the decision making process to determine whether new medical technologies and new uses of existing medical technologies qualify for coverage.As added by P.L.69-1998, SEC.17.
IN Code § 27-13-39-2 (2021)
2021 Indiana Code|Title 27. Insurance|Article 13. Health Maintenance Organizations|Chapter 39. Patient Protection; Experimental Treatments|27-13-39-2. Disclosure of Coverage Limitations

Sec. 2. (a) A health maintenance organization that limits coverage for experimental treatments, procedures, drugs, or devices must clearly state the limitations in any contract, policy, agreement, or certificate of coverage.(b) The disclosure required under subsection (a) must include the following:(1) A description of the process used to make the determination regarding a limitation under subsection (a).(2) A description of the criteria the health maintenance organization uses to determine whether a treatment, procedure, drug, or device is experimental, as provided in section 1 of this chapter.As added by P.L.69-1998, SEC.17.
IN Code § 27-13-39-3 (2021)
2021 Indiana Code|Title 27. Insurance|Article 13. Health Maintenance Organizations|Chapter 39. Patient Protection; Experimental Treatments|27-13-39-3. Written Explanation of Denial of Coverage of Experimental Treatment; Review

Sec. 3. (a) If a health maintenance organization denies coverage for a treatment, procedure, drug, or device on the grounds that the treatment, procedure, drug, or device is experimental, the health maintenance organization shall provide the enrollee with a written explanation that includes the following:(1) The basis for the denial.(2) The enrollee's right to appeal the health maintenance organization's decision as provided in IC 27-8-16-8, IC 27-8-17-12, and IC 27-13-10.(3) The telephone number of:(A) an individual employed by the health maintenance organization whom; or(B) a department of the health maintenance organization that;the enrollee may contact for assistance in initiating an appeal of the health maintenance organization's decision.(b) An enrollee is entitled to a review that takes not more than seventy-two (72) hours if the enrollee's health situation is life threatening or is an emergency.As added by P.L.69-1998, SEC.17.
IN Code § 27-13-40-1 (2021)
2021 Indiana Code|Title 27. Insurance|Article 13. Health Maintenance Organizations|Chapter 40. Patient Protection; Health Maintenance Organization Comparison Sheets|27-13-40-1. Availability of Comparison Sheets

Sec. 1. Beginning January 1, 2000, each health maintenance organization shall make available a health maintenance organization comparison sheet for each policy or contract that either covers or is marketed to an Indiana resident or the resident's employer.As added by P.L.69-1998, SEC.18.
IN Code § 27-13-40-2 (2021)
2021 Indiana Code|Title 27. Insurance|Article 13. Health Maintenance Organizations|Chapter 40. Patient Protection; Health Maintenance Organization Comparison Sheets|27-13-40-2. Requirements for Comparison Sheets

Sec. 2. (a) The comparison sheet required under section 1 of this chapter must include information of general interest to:(1) purchasers of group contracts and individual contracts; and(2) individuals covered by each group contract or individual contract.(b) The comparison sheet must be designed to facilitate comparison of different health maintenance organizations.As added by P.L.69-1998, SEC.18.
IN Code § 27-13-40-3 (2021)
2021 Indiana Code|Title 27. Insurance|Article 13. Health Maintenance Organizations|Chapter 40. Patient Protection; Health Maintenance Organization Comparison Sheets|27-13-40-3. Persons to Be Provided Comparison Sheets

Sec. 3. A health maintenance organization shall provide a completed health maintenance organization comparison sheet to the following:(1) Upon request, to an enrollee or subscriber or to the enrollee's or subscriber's employer.(2) As part of the health maintenance organization's marketing materials, to a person or an employer that may be interested in purchasing or obtaining coverage under a group contract or individual contract offered by the health maintenance organization.As added by P.L.69-1998, SEC.18.