reglab/statecodes huggingface dataset:
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 36. Patient Protection; Clinical Decision Making; Access to Personnel and Facilities › 27-13-36-6. Continuation of Care Provisions

Sec. 6. (a) A health maintenance organization shall include provisions in the health maintenance organization's contracts with providers to provide for continuation of care in the event that a provider's contract with the health maintenance organization is terminated, provided that the termination is not due to a quality of care issue.
(b) The contract provisions under subsection (a) shall require that the provider, upon the request of the enrollee, continue to treat the enrollee for up to sixty (60) days following the termination of the provider's contract with the health maintenance organization or, in the case of a pregnant enrollee in the third trimester of pregnancy, throughout the term of the enrollee's pregnancy. If the provider is a hospital, the contract shall provide for continuation of treatment until the earlier of the following:
(1) Sixty (60) days following the termination of the provider's contract with the health maintenance organization.
(2) The enrollee is released from inpatient status at the hospital.
(c) During a continuation period under this section, the provider:
(1) shall agree to continue accepting the contract terms and conditions, together with applicable deductibles and copayments, as payment in full; and
(2) is prohibited from billing the enrollee for any amounts in excess of the enrollee's applicable deductible or copayment.
As added by P.L.69-1998, SEC.14.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 36. Patient Protection; Clinical Decision Making; Access to Personnel and Facilities › 27-13-36-7. Telephone Access for Authorization of Care

Sec. 7. Each health maintenance organization shall provide the following:
(1) Telephone access to the health maintenance organization during business hours to ensure enrollee access for routine care.
(2) Twenty-four (24) hour telephone access to either:
(A) a representative of the health maintenance organization; or
(B) a participating provider;
for authorization for care.
As added by P.L.69-1998, SEC.14.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 36. Patient Protection; Clinical Decision Making; Access to Personnel and Facilities › 27-13-36-8. Guidelines for Establishing Reasonable Periods for Appointments

Sec. 8. (a) Each health maintenance organization shall establish guidelines for establishing reasonable periods of time within which an enrollee must be given an appointment with a participating provider, except as provided in section 9 of this chapter regarding emergency services.
(b) The guidelines described in subsection (a) must include appointment scheduling guidelines based on the type of health care services most often requested, including the following:
(1) Prenatal care appointments.
(2) Well-child visits and immunizations.
(3) Routine physicals.
(4) Adult preventive services.
(5) Urgent visits.
As added by P.L.69-1998, SEC.14.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 36. Patient Protection; Clinical Decision Making; Access to Personnel and Facilities › 27-13-36-9. Coverage and Reimbursement for Expenses for Care Obtained in an Emergency

Sec. 9. (a) As used in this section, "care obtained in an emergency" means, with respect to an enrollee, covered services that are:
(1) furnished by a provider within the scope of the provider's license and as otherwise authorized under law; and
(2) needed to evaluate or stabilize an individual in an emergency.
(b) As used in this section, "stabilize" means to provide medical treatment to an individual in an emergency as may be necessary to assure, within reasonable medical probability, that material deterioration of the individual's condition is not likely to result from or during any of the following:
(1) The discharge of the individual from an emergency department or other care setting where emergency services are provided to the individual.
(2) The transfer of the individual from an emergency department or other care setting where emergency services are provided to the individual to another health care facility.
(3) The transfer of the individual from a hospital emergency department or other hospital care setting where emergency services are provided to the individual to the hospital's inpatient setting.
(c) As described in subsection (d), each health maintenance organization shall cover and reimburse expenses for care obtained in an emergency by an enrollee without:
(1) prior authorization; or
(2) regard to the contractual relationship between:
(A) the provider who provided health care services to the enrollee in an emergency; and
(B) the health maintenance organization;
in a situation where a prudent lay person could reasonably believe that the enrollee's condition required immediate medical attention. The emergency care obtained by an enrollee under this section includes care for the alleviation of severe pain, which is a symptom of an emergency as provided in IC 27-13-1-11.7.
(d) Each health maintenance organization shall cover and reimburse expenses for emergency services at a rate equal to the lesser of the following:
(1) The usual, customary, and reasonable charge in the health maintenance organization's service area for health care services provided during the emergency.
(2) An amount agreed to between the health maintenance organization and the out of network provider.
A provider that provides emergency services to an enrollee under this section may not charge the enrollee except for an applicable copayment or deductible. Care and treatment provided to an enrollee once the enrollee is stabilized is not care obtained in an emergency.
As added by P.L.69-1998, SEC.14.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 36. Patient Protection; Clinical Decision Making; Access to Personnel and Facilities › 27-13-36-10. Access Plan to Meet Needs of Vulnerable, Underserved, and Non-English Speaking Enrollees

Sec. 10. Each health maintenance organization shall demonstrate to the commissioner that the health maintenance organization has developed an access plan to meet the needs of the health maintenance organization's enrollees, including vulnerable and underserved enrollees and enrollees from major population groups who speak a primary language other than English.
As added by P.L.69-1998, SEC.14.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 36. Patient Protection; Clinical Decision Making; Access to Personnel and Facilities › 27-13-36-11. Standards for Continuity of Care

Sec. 11. The health maintenance organization shall develop standards for continuity of care following enrollment, including sufficient information on how to access care within the health maintenance organization.
As added by P.L.69-1998, SEC.14.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 36. Patient Protection; Clinical Decision Making; Access to Personnel and Facilities › 27-13-36-12. Payment to Enrollee for Service Rendered by Nonparticipating Provider; Requirements

Sec. 12. (a) As used in this section, "nonparticipating provider" means a provider that has not entered into an agreement with a health maintenance organization to serve as a participating provider.
(b) After September 30, 2009, if a health maintenance organization makes a payment to an enrollee for a health care service rendered by a nonparticipating provider, the health maintenance organization shall include with the payment instrument written notice to the enrollee 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 health maintenance organization for each claim.
(4) Any amount of a claim that is the enrollee's responsibility.
(5) A statement in at least 24 point bold type that:
(A) instructs the enrollee to use the payment to pay the nonparticipating provider if the enrollee has not paid the nonparticipating provider in full;
(B) specifies that paying the nonparticipating provider is the enrollee'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.3.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 36.2. Provider Payment › 27-13-36.2-1. "Clean Claim" Defined

Sec. 1. As used in this chapter, "clean claim" means a claim submitted by a provider for payment for health care services provided to an enrollee that has no defect, impropriety, or particular circumstance requiring special treatment preventing payment.
As added by P.L.162-2001, SEC.6.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 36.2. Provider Payment › 27-13-36.2-2. "Health Maintenance Organization" Defined

Sec. 2. As used in this chapter, "health maintenance organization" includes:
(1) an insurance administrator that:
(A) collects charges or premiums; and
(B) adjusts or settles claims;
in connection with coverage under a contract with a health maintenance organization; and
(2) a limited service health maintenance organization.
As added by P.L.162-2001, SEC.6.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 36.2. Provider Payment › 27-13-36.2-3. Notice of Deficiencies in Claims

Sec. 3. (a) A health maintenance organization shall pay or deny each clean claim in accordance with section 4 of this chapter.
(b) A health maintenance organization 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 a health maintenance organization 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.6. Amended by P.L.137-2002, SEC.3.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 36.2. Provider Payment › 27-13-36.2-4. Payment or Denial of Claims; Interest

Sec. 4. (a) A health maintenance organization shall pay or deny each clean claim as follows:
(1) If the claim is filed electronically, not more than thirty (30) days after the date the claim is received by the health maintenance organization.
(2) If the claim is filed on paper, not more than forty-five (45) days after the date the claim is received by the health maintenance organization.
(b) If:
(1) a health maintenance organization fails to pay or deny a clean claim in the time required under subsection (a); and
(2) the health maintenance organization subsequently pays the claim;
the health maintenance organization shall pay the provider that submitted the claim interest on the lesser of the usual, customary, and reasonable charge for the health care services provided to the enrollee or an amount agreed to between the health maintenance organization and the provider paid under this section.
(c) Interest paid under subsection (b):
(1) accrues beginning:
(A) thirty-one (31) days after the date the claim is filed under subsection (a)(1); or
(B) forty-six (46) days after the date the claim is filed under subsection (a)(2); and
(2) stops accruing on the date the claim is paid.
(d) In paying interest under subsection (b), a health maintenance organization shall use the same interest rate as provided in IC 12-15-21-3(7)(A).
As added by P.L.162-2001, SEC.6. Amended by P.L.137-2002, SEC.4.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 36.2. Provider Payment › 27-13-36.2-4.5. Prohibition on Altering Cpt Code for Claim; Exceptions

Sec. 4.5. (a) A health maintenance organization may not alter the CPT code (as defined in IC 27-1-37.5-3) submitted for a clean claim or pay for a CPT code (as defined in IC 27-1-37.5-3) 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 of the participating provider's agreement or contract with the health maintenance organization; or
(2) the medical record of the clean claim has been reviewed by an employee or contractor of the health maintenance organization.
(b) A health maintenance organization may not alter a clean claim to only pay for the CPT codes (as defined in IC 27-1-37.5-3) necessary for an individual's final diagnosis, if the CPT codes (as defined in IC 27-1-37.5-3) billed were deemed medically necessary according to generally accepted clinical care guidelines to reach the final diagnosis.
(c) This section does not prohibit a provider from appealing a claim.
As added by P.L.190-2023, SEC.35.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 36.2. Provider Payment › 27-13-36.2-5. Permitted Forms

Sec. 5. A provider shall submit only the following forms for payment by a health maintenance organization:
(1) CMS-1500.
(2) CMS-1450 (UB-04).
(3) American Dental Association (ADA) claim form.
As added by P.L.162-2001, SEC.6. Amended by P.L.208-2018, SEC.32.
2023 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.
2023 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.
2023 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.
2023 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.
2023 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.
2023 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.
2023 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.
2023 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.
2023 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.
2023 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.
2023 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.
2023 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.
2023 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.
2023 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.
2023 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.
2023 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.
2023 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.
2023 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.
2023 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.
2023 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.
2023 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.
2023 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.
2023 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.
2023 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.
2023 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.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 41. Claims › 27-13-41-1. Use of Diagnostic or Procedure Codes

Sec. 1. Not more than ninety (90) days after the date of the version specified in IC 27-1-1.5 of a diagnostic or procedure code described in this section:
(1) a health maintenance organization and a limited service health maintenance organization shall begin using the version specified in IC 27-1-1.5 of the:
(A) Current Procedural Terminology (CPT);
(B) International Classification of Diseases (ICD);
(C) American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM);
(D) Current Dental Terminology (CDT);
(E) Healthcare Common Procedure Coding System (HCPCS); and
(F) third party administrator (TPA);
codes under which the health maintenance organization and limited service health maintenance organization pay claims for health care services covered under an individual contract or a group contract; and
(2) a provider shall begin using the version specified in IC 27-1-1.5 of the:
(A) Current Procedural Terminology (CPT);
(B) International Classification of Diseases (ICD);
(C) American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM);
(D) Current Dental Terminology (CDT);
(E) Healthcare Common Procedure Coding System (HCPCS); and
(F) third party administrator (TPA);
codes under which the provider submits claims for payment for health care services covered under an individual contract or a group contract.
As added by P.L.161-2001, SEC.5. Amended by P.L.66-2002, SEC.18; P.L.124-2018, SEC.101.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 41. Claims › 27-13-41-2. Reimbursement

Sec. 2. If a provider provides health care services that are covered under an individual contract or a group contract:
(1) after the date of the version specified in IC 27-1-1.5 of a diagnostic or procedure code described in section 1 of this chapter; and
(2) before the health maintenance organization or limited service health maintenance organization begins using the version of the diagnostic or procedure code;
the health maintenance organization or limited service health maintenance organization shall reimburse the provider under the version of the diagnostic or procedure code that was specified in IC 27-1-1.5 on the date that the health care services were provided.
As added by P.L.161-2001, SEC.5. Amended by P.L.124-2018, SEC.102.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 42. Specific Reporting Requirements › 27-13-42-1. Allowing a Health Maintenance Organization to Report the Number of Children Enrollees Who Are Prescribed Stimulant Medication for the Treatment of Certain Disorders

Sec. 1. A health maintenance organization that enters into an individual contract or a group contract that provides a prescription drug benefit may report to the drug utilization review board established by IC 12-15-35-19, not later than October 1 of each calendar year, the number of enrollees who are:
(1) less than eighteen (18) years of age; and
(2) prescribed a stimulant medication approved by the federal Food and Drug Administration for the treatment of attention deficit disorder or attention deficit hyperactivity disorder.
As added by P.L.107-2002, SEC.30.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 43. Credentialing › 27-13-43-1. Application of Chapter

Sec. 1. (a) Except as provided in subsection (b), this chapter applies to a health maintenance organization that provides basic health care services.
(b) This chapter does not apply to the credentialing of a provider by a health maintenance organization if the provider's application for credentialing is only for purposes of providing health care services to the following:
(1) A Medicaid recipient under a Medicaid risk based managed care program described in IC 12-15-12.
(2) An individual who is covered under the children's health insurance program established under IC 12-17.6-2.
As added by P.L.26-2005, SEC.4.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 43. Credentialing › 27-13-43-2. Provider Credentialing

Note: This version of section effective until 1-1-2024. See also following version of this section, effective 1-1-2024.
Sec. 2. (a) The department shall prescribe the credentialing application form used by the Council for Affordable Quality Healthcare (CAQH) in electronic or paper format. The form must be used by:
(1) a provider who applies for credentialing by a health maintenance organization; and
(2) a health maintenance organization that performs credentialing activities.
(b) A health maintenance organization 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 health maintenance organization receives the completed credentialing application form.
(c) A health maintenance organization shall notify a provider concerning the status of the provider's completed credentialing application not later than:
(1) sixty (60) days after the health maintenance organization receives the completed credentialing application form; and
(2) every thirty (30) days after the notice is provided under subdivision (1), until the health maintenance organization makes a final credentialing determination concerning the provider.
As added by P.L.26-2005, SEC.4. Amended by P.L.1-2006, SEC.489.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 43. Credentialing › 27-13-43-3. Provisional Credentialing; Criteria; Reimbursement; Termination

Note: This version of section effective until 1-1-2024. See also following repeal of this section, effective 1-1-2024.
Sec. 3. (a) Notwithstanding section 2 of this chapter, if a health maintenance organization fails to issue a credentialing determination within thirty (30) days after receiving a completed credentialing application form from a provider, the health maintenance organization shall provisionally credential the provider if the provider meets the following criteria:
(1) The provider has submitted a completed and signed credentialing application form and any required supporting material to the health maintenance organization.
(2) The provider was previously credentialed by the health maintenance organization in Indiana and in the same scope of practice for which the provider has applied for provisional credentialing.
(3) The provider is a member of a provider group that is credentialed and a participating provider with the health maintenance organization.
(4) The provider is a network provider with the health maintenance organization.
(b) The criteria for issuing provisional credentialing under subsection (a) may not be less stringent than the standards and guidelines governing provisional credentialing from the National Committee for Quality Assurance or its successor organization.
(c) Once a health maintenance organization fully credentials a provider that holds provisional credentialing, reimbursement payments under the contract shall be retroactive to the date of the provisional credentialing. The health maintenance organization shall reimburse the provider at the rates determined by the contract between the provider and the health maintenance organization.
(d) If a health maintenance organization does not fully credential a provider that is provisionally credentialed under subsection (a), the provisional credentialing is terminated on the date the health maintenance organization notifies the provider of the adverse credentialing determination. The health maintenance organization is not required to reimburse for services rendered while the provider was provisionally credentialed.
As added by P.L.195-2018, SEC.19.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 43. Credentialing › 27-13-43-3-b. Repealed

Note: This repeal of section effective 1-1-2024. See also preceding version of this section, effective until 1-1-2024.
As added by P.L.195-2018, SEC.19. Repealed by P.L.190-2023, SEC.37.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 43. Credentialing › 27-13-43-3.5. Provisional Credentialing for Independent Primary Care Practice Physicians; Criteria

Sec. 3.5. (a) A physician licensed under IC 25-22.5 who was credentialed with a health maintenance organization to provide services within the previous twelve (12) months shall be considered provisionally credentialed if the physician:
(1) is in good standing with the health maintenance organization; and
(2) establishes or joins an independent primary care practice.
(b) The health maintenance organization shall complete the credentialing process for an individual who is provisionally credentialed under subsection (a).
As added by P.L.203-2023, SEC.24.
2023 Indiana Code › Title 27. Insurance › Article 13. Health Maintenance Organizations › Chapter 43. Credentialing › 27-13-43-4. Fully Credentialed Provider Reimbursement; Requirements

Sec. 4. (a) A fully credentialed provider shall be reimbursed for eligible services provided at any in-network hospital if the following conditions are met:
(1) The provider submits the documentation required by the health maintenance organization to be loaded under the provider group or hospital.
(2) The provider, provider group, or hospital is a network provider with the health maintenance organization.
(3) The services are provided in accordance with all terms and conditions of the provider's, group provider's, or hospital's agreement or contract with the health maintenance organization.
(4) Prior authorization is obtained in accordance with IC 27-1-37.5 when required by the health maintenance organization for an eligible service.
(b) The health maintenance organization shall reimburse the provider or hospital for services described in subsection (a) at the rates determined by the contract between the provider and the health maintenance organization.
(c) A health maintenance organization is not required to credential a provider. However, if:
(1) a provider is employed by a hospital that is part of the hospital's network that is covered by the health maintenance organization; and
(2) the provider meets the health maintenance organization's credentialing requirements;
the health maintenance organization shall reimburse the provider for any reimbursable services from the date that the provider was employed by the hospital.
As added by P.L.50-2020, SEC.9.
2023 Indiana Code › Title 27. Insurance › Article 14.5. Mutual Insurance Holding Company Law › Chapter 1. General Provisions and Definitions › 27-14.5-1-2. Repeal of Former Law

Sec. 2. (a) This article replaces IC 27-14, as repealed by this House Enrolled Act 1329-2023.
(b) The repeal of IC 27-14 does not affect the validity of any mutual insurance company reorganization that was approved under IC 27-14. Any existing mutual insurance holding company and any related intermediate stock holding company or reorganized insurer created or reorganized under IC 27-14 (before its repeal) are:
(1) governed by this article after April 30, 2023; and
(2) considered created or reorganized as of the date the mutual insurance holding company, related intermediate stock holding company, or reorganized insurer was created or reorganized, as applicable, under IC 27-14.
As added by P.L.226-2023, SEC.30.