reglab/statecodes huggingface dataset:
2023 Indiana Code › Title 27. Insurance › Article 1. Department of Insurance › Chapter 37.3. Third Party Rights and Responsibilities Under Health Care Contracts › 27-1-37.3-7. Granting Access to Contracted Health Care Services; Requirements

Sec. 7. A contractor may not lease, rent, or otherwise grant access to a provider's health care services under a health care contract unless the contractor complies with one (1) of the following:
(1) The third party to which the access is granted is:
(A) an employer or another entity providing coverage for health care services to the employer's or entity's employees or members and the entity has a contract with the contractor or the contractor's affiliate for the administration or processing of claims for payment or service provided under the health care contract; or
(B) an affiliate or a subsidiary of the contractor or providing administrative services to or receiving administrative services from the contractor or the contractor's affiliate or subsidiary.
(2) The:
(A) health care contract specifically states that the contractor may lease, rent, or otherwise grant access to the provider's health care services under the health care contract;
(B) third party accessing the health care contract is:
(i) a payer or third party administrator or another entity that administers claims on behalf of the payer;
(ii) a preferred provider organization or preferred provider network, including a physician-hospital organization; or
(iii) an entity engaged in the electronic claims transport between the contractor and the payer; and
(C) third party that is granted access to the provider's health care services under the health care contract is obligated to comply with all the applicable terms of the health care contract.
As added by P.L.55-2008, SEC.1.
2023 Indiana Code › Title 27. Insurance › Article 1. Department of Insurance › Chapter 37.3. Third Party Rights and Responsibilities Under Health Care Contracts › 27-1-37.3-8. List of Third Parties With Access to Contracted Health Care Services

Sec. 8. (a) A contractor that leases, rents, or otherwise grants access to a provider's health care services as described in section 7(2) of this chapter shall maintain an Internet web page or a toll free telephone number through which the provider may obtain a listing, updated at least semiannually, of the third parties to which access to the provider's health care services has been granted.
(b) A contractor shall, at the time a health care contract is entered into with a provider, identify and provide any preferred provider organization, preferred provider network, physician hospital organization, or other entity identified in section 7(2)(B)(ii) of this chapter that is known at the time of contracting, to which the contractor will grant access to the provider's health care services under section 7 of this chapter.
As added by P.L.55-2008, SEC.1.
2023 Indiana Code › Title 27. Insurance › Article 1. Department of Insurance › Chapter 37.3. Third Party Rights and Responsibilities Under Health Care Contracts › 27-1-37.3-9. Identification of Contractual Source of Discounts

Sec. 9. A contractor that leases, rents, or otherwise grants access to a provider's health care services under section 7 of this chapter shall ensure that an explanation of benefits or remittance advice furnished to the provider that delivers health care services under the health care contract identifies the contractual source of any discount that applies.
As added by P.L.55-2008, SEC.1.
2023 Indiana Code › Title 27. Insurance › Article 1. Department of Insurance › Chapter 37.3. Third Party Rights and Responsibilities Under Health Care Contracts › 27-1-37.3-10. Termination of Third Party Rights

Sec. 10. Subject to applicable continuity of care requirements, a third party's right to exercise a contractor's rights and responsibilities under a health care contract terminates on the date that the health care contract is terminated.
As added by P.L.55-2008, SEC.1.
2023 Indiana Code › Title 27. Insurance › Article 1. Department of Insurance › Chapter 37.4. Electronic Prescription Drug Prior Authorization › 27-1-37.4-2. "Health Plan"

Sec. 2. As used in this chapter, "health plan" means any of the following that provides coverage for prescription drugs:
(1) A policy of accident and sickness insurance (as defined in IC 27-8-5-1).
(2) A contract with a health maintenance organization (as defined in IC 27-13-1-19).
The term includes a person that administers a policy or contract described in subdivision (1) or (2).
As added by P.L.45-2017, SEC.1.
2023 Indiana Code › Title 27. Insurance › Article 1. Department of Insurance › Chapter 37.4. Electronic Prescription Drug Prior Authorization › 27-1-37.4-3. "Prior Authorization"

Sec. 3. As used in this chapter, "prior authorization" includes a health plan requirement that a prescription drug be authorized for payment by the health plan before the prescription drug is provided to a particular covered individual.
As added by P.L.45-2017, SEC.1.
2023 Indiana Code › Title 27. Insurance › Article 1. Department of Insurance › Chapter 37.4. Electronic Prescription Drug Prior Authorization › 27-1-37.4-4. Electronic Transmission of Prior Authorization Request

Sec. 4. A health plan shall accept and respond to a request for prior authorization delivered to the health plan by a covered individual's:
(1) prescribing health care provider; or
(2) dispensing pharmacist;
through an electronic transmission that complies with the technical standards developed by the National Council for Prescription Drug Programs for electronic prior authorization transactions (NCPDP SCRIPT).
As added by P.L.45-2017, SEC.1.
2023 Indiana Code › Title 27. Insurance › Article 1. Department of Insurance › Chapter 37.4. Electronic Prescription Drug Prior Authorization › 27-1-37.4-5. Application of Chapter

Sec. 5. Section 4 of this chapter does not apply if a prescribing health care provider or dispensing pharmacist lacks:
(1) broadband Internet access;
(2) an electronic medical record system; or
(3) a sufficient number of covered individuals as patients or customers, as determined by the commissioner, to warrant the financial expense that compliance with section 4 of this chapter would require.
As added by P.L.45-2017, SEC.1.
2023 Indiana Code › Title 27. Insurance › Article 1. Department of Insurance › Chapter 37.4. Electronic Prescription Drug Prior Authorization › 27-1-37.4-6. Contradictory Contract Provisions

Sec. 6. A contractual provision that:
(1) is contained in a contract that is entered into, amended, or renewed after December 31, 2017; and
(2) contradicts this chapter;
is void.
As added by P.L.45-2017, SEC.1.
2023 Indiana Code › Title 27. Insurance › Article 1. Department of Insurance › Chapter 37.4. Electronic Prescription Drug Prior Authorization › 27-1-37.4-8. "Step Therapy Protocol"; Notice of Denial; Required Information

Sec. 8. (a) As used in this section, "step therapy protocol" means a protocol that specifies, as a condition of coverage under a health plan, the order in which certain prescription drugs must be used to treat a covered individual's condition.
(b) A health plan that denies prior authorization for a prescription drug described in subdivision (1) or (2) shall provide, in the notice of denial, an alternative list of prescription drugs or alternative treatments as follows:
(1) If:
(A) the prescription drug is not included in the health plan's formulary; and
(B) there is at least one (1) alternative prescription drug in the same therapeutic classification (as defined in IC 12-15-35-17.5);
the alternative list must specify the alternative prescription drugs described in clause (B) that are covered by the health plan.
(2) If the prescription drug is prescribed to treat a condition for which coverage under the health plan requires use of a step therapy protocol, the alternative list must specify the alternative prescription drugs or alternative treatments that are required by the step therapy protocol.
As added by P.L.246-2019, SEC.23 and P.L.264-2019, SEC.12.
2023 Indiana Code › Title 27. Insurance › Article 1. Department of Insurance › Chapter 37.5. Health Care Service Prior Authorization › 27-1-37.5-1. Application of Chapter

Sec. 1. (a) Except as provided in sections 10, 11, 12, 13, and 13.5 of this chapter, this chapter applies beginning September 1, 2018.
(b) This chapter does not apply to a step therapy protocol exception procedure under IC 27-8-5-30 or IC 27-13-7-23.
(c) This chapter does not apply to a health plan that is offered by a local unit public employer under a program of group health insurance provided under IC 5-10-8-2.6.
As added by P.L.77-2018, SEC.2. Amended by P.L.190-2023, SEC.13.
2023 Indiana Code › Title 27. Insurance › Article 1. Department of Insurance › Chapter 37.5. Health Care Service Prior Authorization › 27-1-37.5-1.5. "Adverse Determination"

Sec. 1.5. As used in this chapter, "adverse determination" means a denial of a request for benefits on the grounds that the health service or item:
(1) is not medically necessary, appropriate, effective, or efficient;
(2) is not being provided in or at an appropriate health care setting or level of care; or
(3) is experimental or investigational.
As added by P.L.190-2023, SEC.14.
2023 Indiana Code › Title 27. Insurance › Article 1. Department of Insurance › Chapter 37.5. Health Care Service Prior Authorization › 27-1-37.5-1.7. "Clinical Peer"

Sec. 1.7. As used in this chapter, "clinical peer" means a practitioner or other health care provider who either:
(1) holds a current and valid license in any United States jurisdiction;
(2) has been granted reciprocity in the state, if reciprocity exists; or
(3) holds a license that is part of a compact in which the state has entered.
As added by P.L.190-2023, SEC.15.
2023 Indiana Code › Title 27. Insurance › Article 1. Department of Insurance › Chapter 37.5. Health Care Service Prior Authorization › 27-1-37.5-3. "Cpt Code"

Sec. 3. As used in this chapter, "CPT code" refers to the medical billing code that applies to a specific health care service, as published in the Current Procedural Terminology code set maintained by the American Medical Association.
As added by P.L.77-2018, SEC.2.
2023 Indiana Code › Title 27. Insurance › Article 1. Department of Insurance › Chapter 37.5. Health Care Service Prior Authorization › 27-1-37.5-4. "Health Care Service"

Sec. 4. (a) As used in this chapter, "health care service" means a health care related service or product rendered or sold by a health care provider within the scope of the health care provider's license or legal authorization, including hospital, medical, surgical, mental health, and substance abuse services or products.
(b) The term does not include the following:
(1) Dental services.
(2) Vision services.
(3) Long term rehabilitation treatment.
(4) Pharmaceutical services or products.
As added by P.L.77-2018, SEC.2.
2023 Indiana Code › Title 27. Insurance › Article 1. Department of Insurance › Chapter 37.5. Health Care Service Prior Authorization › 27-1-37.5-5. "Health Plan"

Sec. 5. (a) As used in this chapter, "health plan" means any of the following that provides coverage for health care services:
(1) A policy of accident and sickness insurance (as defined in IC 27-8-5-1). However, the term does not include the coverages described in IC 27-8-5-2.5(a).
(2) A contract with a health maintenance organization (as defined in IC 27-13-1-19) that provides coverage for basic health care services (as defined in IC 27-13-1-4).
(3) After December 31, 2020, the Medicaid risk based managed care program under IC 12-15.
(b) The term includes a person that administers any of the following:
(1) A policy described in subsection (a)(1).
(2) A contract described in subsection (a)(2).
(3) A self-insurance program established under IC 5-10-8-7(b) to provide health care coverage.
(4) After December 31, 2020, Medicaid risk based managed care.
As added by P.L.77-2018, SEC.2. Amended by P.L.265-2019, SEC.3.
2023 Indiana Code › Title 27. Insurance › Article 1. Department of Insurance › Chapter 37.5. Health Care Service Prior Authorization › 27-1-37.5-6. "Participating Provider"

Sec. 6. As used in this chapter, "participating provider" refers to the following:
(1) A health care provider that has entered into an agreement with an insurer under IC 27-8-11-3.
(2) A participating provider (as defined in IC 27-13-1-24).
As added by P.L.77-2018, SEC.2.
2023 Indiana Code › Title 27. Insurance › Article 1. Department of Insurance › Chapter 37.5. Health Care Service Prior Authorization › 27-1-37.5-7. "Prior Authorization"

Sec. 7. As used in this chapter, "prior authorization" means a practice implemented by a health plan through which coverage of a health care service is dependent on the covered individual or health care provider obtaining approval from the health plan before the health care service is rendered. The term includes prospective or utilization review procedures conducted before a health care service is rendered.
As added by P.L.77-2018, SEC.2.
2023 Indiana Code › Title 27. Insurance › Article 1. Department of Insurance › Chapter 37.5. Health Care Service Prior Authorization › 27-1-37.5-8. "Urgent Care Situation"

Sec. 8. As used in this chapter, "urgent care situation" means a situation in which a covered individual's treating physician has determined that the covered individual's condition is likely to result in:
(1) adverse health consequences or serious jeopardy to the covered individual's life, health, or safety; or
(2) due to the covered individual's psychological state, serious jeopardy to the life, health, or safety of another individual;
unless treatment of the covered individual's condition for which prior authorization is sought occurs earlier than the period generally considered by the medical profession to be reasonable to treat routine or non-life threatening conditions.
As added by P.L.77-2018, SEC.2.
2023 Indiana Code › Title 27. Insurance › Article 1. Department of Insurance › Chapter 37.5. Health Care Service Prior Authorization › 27-1-37.5-9. Availability of Prior Authorization Information; Requirements; New Requirements; Address Change; Notices

Sec. 9. (a) A health plan shall make available to participating providers on the health plan's Internet web site or portal the applicable CPT code for the specific health care services for which prior authorization is required.
(b) A health plan shall make available to participating providers, on the health plan's Internet web site or portal, a list of the health plan's prior authorization requirements, including specific information that a provider must submit to establish a complete request for prior authorization. This subsection does not prevent a health plan from requiring specific additional information upon review of the request for prior authorization.
(c) A health plan shall, not less than forty-five (45) days before the prior authorization requirement becomes effective, disclose to a participating provider any new prior authorization requirement.
(d) A disclosure made under subsection (c) must:
(1) be sent via electronic or United States mail and conspicuously labeled "Notice of Changes to Prior Authorization Requirements"; and
(2) specifically identify the location on the health plan's Internet web site or portal of the new prior authorization requirement.
However, a health plan is considered to have met the requirements of this subsection if the health plan conspicuously posts the information required by this subsection, including the effective date of the new prior authorization requirement, on the health plan's Internet web site.
(e) A participating provider shall, not more than seven (7) days after the change is made, notify the health plan of a change in the participating provider's electronic or United States mail address.
As added by P.L.77-2018, SEC.2.
2023 Indiana Code › Title 27. Insurance › Article 1. Department of Insurance › Chapter 37.5. Health Care Service Prior Authorization › 27-1-37.5-10. Request for Prior Authorization; Electronic Transmission; Standardized Form

Sec. 10. (a) This section applies to a request for prior authorization delivered to a health plan after December 31, 2019.
(b) A health plan shall accept a request for prior authorization delivered to the health plan by a covered individual's health care provider through a secure electronic transmission. A health care provider shall submit a request for prior authorization through a secure electronic transmission. A health plan shall provide for:
(1) a secure electronic transmission; and
(2) acknowledgment of receipt, by use of a transaction number or another reference code;
of a request for prior authorization and any supporting information.
(c) Subsection (b) does not apply and a health plan that requires prior authorization shall accept a request for prior authorization that is not submitted through a secure electronic transmission if a covered individual's health care provider and the health plan have entered into an agreement under which the health plan agrees to process prior authorization requests that are not submitted through a secure electronic transmission because:
(1) secure electronic transmission of prior authorization requests would cause financial hardship for the health care provider;
(2) the area in which the health care provider is located lacks sufficient Internet access; or
(3) the health care provider has an insufficient number of covered individuals as patients or customers, as determined by the commissioner, to warrant the financial expense that compliance with subsection (b) would require.
(d) If a covered individual's health care provider is described in subsection (c), the health plan shall accept from the health care provider a request for prior authorization as follows:
(1) The prior authorization request must be made on the standardized prior authorization form established by the department under section 16 of this chapter.
(2) The health plan shall provide for secure electronic transmission and acknowledgement of receipt of the standardized prior authorization form and any supporting information for the prior authorization by use of a transaction number or another reference code.
As added by P.L.77-2018, SEC.2. Amended by P.L.208-2018, SEC.8.
2023 Indiana Code › Title 27. Insurance › Article 1. Department of Insurance › Chapter 37.5. Health Care Service Prior Authorization › 27-1-37.5-11. Response to Request for Prior Authorization; Timing; Incomplete Request

Sec. 11. (a) This section applies to a prior authorization request delivered to a health plan after December 31, 2019.
(b) A health plan shall respond to a request delivered under section 10 of this chapter as follows:
(1) If the request is delivered under section 10(b) of this chapter, the health plan shall immediately send to the requesting health care provider an electronic receipt for the request.
(2) If the request is for an urgent care situation, the health plan shall respond with a prior authorization determination not more than forty-eight (48) hours after receiving the request.
(3) If the request is for a nonurgent care situation, the health plan shall respond with a prior authorization determination not more than five (5) business days after receiving the request.
(c) If a request delivered under section 10 of this chapter is incomplete:
(1) the health plan shall respond within the period required by subsection (b) and indicate the specific additional information required to process the request;
(2) if the request was delivered under section 10(b) of this chapter, upon receiving the response under subdivision (1), the health care provider shall immediately send to the health plan an electronic receipt for the response made under subdivision (1); and
(3) if the request is for an urgent care situation, the health care provider shall respond to the request for additional information not more than forty-eight (48) hours after the health care provider receives the response under subdivision (1).
(d) If a request delivered under section 10 of this chapter is denied, the health plan shall respond within the period required by subsection (b) and indicate the specific reason for the denial in clear and easy to understand language.
As added by P.L.77-2018, SEC.2. Amended by P.L.190-2023, SEC.16.
2023 Indiana Code › Title 27. Insurance › Article 1. Department of Insurance › Chapter 37.5. Health Care Service Prior Authorization › 27-1-37.5-12. Claim for Which Prior Authorization Was Given; Denial; Resubmission of Claim

Sec. 12. (a) This section applies to a claim for a health care service rendered by a participating provider:
(1) for which:
(A) prior authorization is requested after December 31, 2019; and
(B) a health plan gives prior authorization; and
(2) that is rendered in accordance with:
(A) the prior authorization; and
(B) all terms and conditions of the participating provider's agreement or contract with the health plan.
(b) The health plan shall not deny the claim described in subsection (a) unless:
(1) the:
(A) request for prior authorization; or
(B) claim;
contains fraudulent or materially incorrect information; or
(2) the covered individual is not covered under the health plan on the date on which the health care service is rendered.
(c) If:
(1) the claim described in subsection (a) contains an unintentional and inaccurate inconsistency with the request for prior authorization; and
(2) the inconsistency results in denial of the claim;
the health care provider may resubmit the claim with accurate, corrected information.
As added by P.L.77-2018, SEC.2.
2023 Indiana Code › Title 27. Insurance › Article 1. Department of Insurance › Chapter 37.5. Health Care Service Prior Authorization › 27-1-37.5-13. Unanticipated, Medically Necessary Health Care Service; Denial; Payment for Health Care Service With Prior Authorization

Sec. 13. (a) This section applies to a claim filed after December 31, 2018, for a medically necessary health care service rendered by a participating provider, the necessity of which:
(1) is not anticipated at the time prior authorization is obtained for another health care service; and
(2) is determined at the time the other health care service is rendered.
(b) The health plan shall not deny a claim described in subsection (a) based solely on lack of prior authorization for the unanticipated health care service.
(c) The health plan:
(1) shall not deny payment for a health care service that is rendered in accordance with:
(A) a prior authorization; and
(B) all terms and conditions of the participating provider's agreement or contract with the health plan; and
(2) may:
(A) require retrospective review of; and
(B) withhold payment for;
an unanticipated health care service described in subsection (a).
As added by P.L.77-2018, SEC.2.
2023 Indiana Code › Title 27. Insurance › Article 1. Department of Insurance › Chapter 37.5. Health Care Service Prior Authorization › 27-1-37.5-13.5. State Employee Health Plan Prohibited From Requiring Prior Authorization for Certain Cpt Codes; Retroactive Denial; Review of Impact

Sec. 13.5. (a) This section applies only to the state employee health plan (as defined in IC 5-10-8-6.7(a)).
(b) The state employee health plan may not require a participating provider to obtain prior authorization for the following CPT codes:
(1) 11200.
(2) 11201.
(3) 17311.
(4) 17312.
(5) 17313.
(6) 17314.
(7) 44140.
(8) 44160.
(9) 44970.
(10) 49505.
(11) 70450.
(12) 70551.
(13) 70552.
(14) 70553.
(15) 71250.
(16) 71260.
(17) 71275.
(18) 72141.
(19) 72148.
(20) 72158.
(21) 73221.
(22) 73721.
(23) 74150.
(24) 74160.
(25) 74176.
(26) 74177.
(27) 74178.
(28) 74179.
(29) 74181.
(30) 74183.
(31) 78452.
(32) 92507.
(33) 92526.
(34) 92609.
(35) 93303.
(36) 93306.
(37) 95044.
(38) 95806.
(39) 95810.
(40) 97110.
(41) 97112.
(42) 97116.
(43) 97129.
(44) 97130.
(45) 97140.
(46) 97530.
(47) V5010.
(48) V5256.
(49) V5261.
(50) V5275.
(c) The state employee health plan may not issue a retroactive denial for medical necessity for a CPT code listed in subsection (b).
(d) Before November 1, 2025, the:
(1) interim study committee on public health, behavioral health, and human services; and
(2) interim study committee on financial institutions and insurance;
shall jointly review the impact of this section, including any relief on the administrative burdens to participating providers and any differences in utilization of the CPT codes listed in subsection (b).
(e) This section expires June 30, 2026.
As added by P.L.190-2023, SEC.17.
2023 Indiana Code › Title 27. Insurance › Article 1. Department of Insurance › Chapter 37.5. Health Care Service Prior Authorization › 27-1-37.5-14. Contrary Contract Provision Void

Sec. 14. A provision that:
(1) is contained in a policy or contract that is entered into, amended, or renewed after June 30, 2018; and
(2) contradicts this chapter;
is void.
As added by P.L.77-2018, SEC.2.
2023 Indiana Code › Title 27. Insurance › Article 1. Department of Insurance › Chapter 37.5. Health Care Service Prior Authorization › 27-1-37.5-15. Violation of Chapter

Sec. 15. A violation of this chapter by a health plan is an unfair or deceptive act or practice in the business of insurance under IC 27-4-1-4.
As added by P.L.77-2018, SEC.2.
2023 Indiana Code › Title 27. Insurance › Article 1. Department of Insurance › Chapter 37.5. Health Care Service Prior Authorization › 27-1-37.5-16. Department of Insurance; Standardized Prior Authorization Form

Sec. 16. (a) Except as provided in subsection (b), the department shall establish, post, and maintain on the department's Internet web site a standardized prior authorization form for use by health care providers and health plans for purposes of any notice or authorization required by a health plan with respect to payment for a health care service rendered to a covered individual.
(b) After December 31, 2020, a Medicaid managed care organization (as defined in IC 12-7-2-126.9) shall use a standardized prior authorization form prescribed by the office of the secretary of family and social services.
As added by P.L.77-2018, SEC.2. Amended by P.L.265-2019, SEC.4.
2023 Indiana Code › Title 27. Insurance › Article 1. Department of Insurance › Chapter 37.5. Health Care Service Prior Authorization › 27-1-37.5-17. Peer to Peer Review; Request

Sec. 17. (a) As used in this section, "necessary information" includes the results of any face-to-face clinical evaluation, second opinion, or other clinical information that is directly applicable to the requested service that may be required.
(b) If a health plan makes an adverse determination on a prior authorization request by a covered individual's health care provider, the health plan must offer the covered individual's health care provider the option to request a peer to peer review by a clinical peer concerning the adverse determination.
(c) A covered individual's health care provider may request a peer to peer review by a clinical peer either in writing or electronically.
(d) If a peer to peer review by a clinical peer is requested under this section:
(1) the health plan's clinical peer and the covered individual's health care provider or the health care provider's designee shall make every effort to provide the peer to peer review not later than seven (7) business days from the date of receipt by the health plan of the request by the covered individual's health care provider for a peer to peer review if the health plan has received the necessary information for the peer to peer review; and
(2) the health plan must have the peer to peer review conducted between the clinical peer and the covered individual's health care provider or the provider's designee.
As added by P.L.190-2023, SEC.18.
2023 Indiana Code › Title 27. Insurance › Article 1. Department of Insurance › Chapter 37.6. Program to Reduce or Eliminate Prior Authorization Requirements for Health Care Providers › 27-1-37.6-1. "Bundled Payments"

Sec. 1. As used in this chapter, "bundled payments" means a reimbursement structure in which different health care providers who are treating a patient for the same or related conditions are paid an overall sum for treating a patient's condition rather than being paid for each individual treatment, test, or procedure.
As added by P.L.203-2023, SEC.19.
2023 Indiana Code › Title 27. Insurance › Article 1. Department of Insurance › Chapter 37.6. Program to Reduce or Eliminate Prior Authorization Requirements for Health Care Providers › 27-1-37.6-2. "Capitated Rate Reimbursement Arrangement"

Sec. 2. As used in this chapter, "capitated rate reimbursement arrangement" means a fixed amount of money per patient per unit of time paid in advance to the health care provider for the delivery of health care services.
As added by P.L.203-2023, SEC.19.
2023 Indiana Code › Title 27. Insurance › Article 1. Department of Insurance › Chapter 37.6. Program to Reduce or Eliminate Prior Authorization Requirements for Health Care Providers › 27-1-37.6-3. "Downside Risk"

Sec. 3. As used in this chapter, "downside risk" means the risk borne by health care providers in a situation in which, if the total cost of care exceeds projected or budgeted costs, the health care providers will be responsible for a defined percentage of the amount by which the total cost of care exceeds the projected or budgeted costs.
As added by P.L.203-2023, SEC.19.
2023 Indiana Code › Title 27. Insurance › Article 1. Department of Insurance › Chapter 37.6. Program to Reduce or Eliminate Prior Authorization Requirements for Health Care Providers › 27-1-37.6-4. "Electronic Medical Record"

Sec. 4. As used in this chapter, "electronic medical record":
(1) means a digital collection of medical information about a person that is stored on a computer, electronic platform, or cloud that is automated or permitted to be accessed; and
(2) includes information about a patient's health history, such as:
(A) diagnoses;
(B) medicines;
(C) tests;
(D) allergies; and
(E) treatment plans.
As added by P.L.203-2023, SEC.19.
2023 Indiana Code › Title 27. Insurance › Article 1. Department of Insurance › Chapter 37.6. Program to Reduce or Eliminate Prior Authorization Requirements for Health Care Providers › 27-1-37.6-5. "Electronic Medical Records Access Agreement"

Sec. 5. As used in this chapter, "electronic medical records access agreement" means an agreement between a health plan and health care provider that:
(1) authorizes the health plan to access the provider's electronic medical records; or
(2) allows the transfer of automated medical records information between a health care provider and health plan.
As added by P.L.203-2023, SEC.19.
2023 Indiana Code › Title 27. Insurance › Article 1. Department of Insurance › Chapter 37.6. Program to Reduce or Eliminate Prior Authorization Requirements for Health Care Providers › 27-1-37.6-6. "Fixed Fee Schedule"

Sec. 6. As used in this chapter, "fixed fee schedule" means a total listing of fees used by a health plan to reimburse health care providers or facilities whether:
(1) the fixed fee schedule is based on or equal to Medicare reimbursement for the same health care service; or
(2) the health plan provides the fixed fee schedule to the health care provider.
As added by P.L.203-2023, SEC.19.
2023 Indiana Code › Title 27. Insurance › Article 1. Department of Insurance › Chapter 37.6. Program to Reduce or Eliminate Prior Authorization Requirements for Health Care Providers › 27-1-37.6-7. "Health Care Provider"

Sec. 7. As used in this chapter, "health care provider" means an individual or entity that is:
(1) licensed, certified, registered, or regulated by an entity described in IC 25-0.5-11;
(2) authorized to provide health care services; and
(3) contracted to provide health care services to members of a health plan.
As added by P.L.203-2023, SEC.19.
2023 Indiana Code › Title 27. Insurance › Article 1. Department of Insurance › Chapter 37.6. Program to Reduce or Eliminate Prior Authorization Requirements for Health Care Providers › 27-1-37.6-8. "Health Care Service"

Sec. 8. (a) As used in this chapter, "health care service" means a medical or surgical service for the diagnosis, prevention, treatment, cure, or relief of illness, injury, or disease that is measured at the diagnosis and procedure level for an individual health care provider.
(b) The term does not include the following:
(1) Dental services.
(2) Vision services.
(3) Long term rehabilitation treatment.
(4) Pharmaceutical or pharmacist services or products.
As added by P.L.203-2023, SEC.19.
2023 Indiana Code › Title 27. Insurance › Article 1. Department of Insurance › Chapter 37.6. Program to Reduce or Eliminate Prior Authorization Requirements for Health Care Providers › 27-1-37.6-9. "Health Plan"

Sec. 9. (a) As used in this chapter, "health plan" means any of the following:
(1) A policy of accident and sickness insurance (as defined in IC 27-8-5-1). However, the term does not include the coverages described in IC 27-8-5-2.5(a).
(2) A contract with a health maintenance organization (as defined in IC 27-13-1-19) that provides coverage for basic health care services (as defined in IC 27-13-1-4).
(3) A self-insurance program established under IC 5-10-8-7(b) to provide health care coverage.
(b) The term includes the following:
(1) The insurer that issues a policy of accident and sickness insurance described in subsection (a)(1).
(2) The health maintenance organization referred to in subsection (a)(2).
(3) The entity with which the state contracts for the administration of the self-insurance program established under IC 5-10-8-7(b) to provide health care coverage.
(c) The term does not include a Medicaid managed care organization, as defined in IC 12-7-2-126.9.
As added by P.L.203-2023, SEC.19.
2023 Indiana Code › Title 27. Insurance › Article 1. Department of Insurance › Chapter 37.6. Program to Reduce or Eliminate Prior Authorization Requirements for Health Care Providers › 27-1-37.6-10. "Narrow Network"

Sec. 10. As used in this chapter, "narrow network" means a network:
(1) significantly limited to select health care providers that offer a range of health care services to health plan members; and
(2) for which any other health care provider that is not included in the network is an out of network health care provider.
As added by P.L.203-2023, SEC.19.
2023 Indiana Code › Title 27. Insurance › Article 1. Department of Insurance › Chapter 37.6. Program to Reduce or Eliminate Prior Authorization Requirements for Health Care Providers › 27-1-37.6-11. "Pay for Performance Arrangement"

Sec. 11. As used in this chapter, "pay for performance arrangement" means a reimbursement model that reimburses health care providers for meeting predefined targets as defined in the agreement for quality indicators or efficacy parameters to increase the quality or efficacy of care.
As added by P.L.203-2023, SEC.19.
2023 Indiana Code › Title 27. Insurance › Article 1. Department of Insurance › Chapter 37.6. Program to Reduce or Eliminate Prior Authorization Requirements for Health Care Providers › 27-1-37.6-12. "Prior Authorization"

Sec. 12. As used in this chapter, "prior authorization" means a practice implemented by a health plan through which coverage of a health care service is dependent on the covered individual or health care provider obtaining approval from the health plan before the health care service is rendered. The term includes prospective or utilization review procedures conducted before a health care service is rendered.
As added by P.L.203-2023, SEC.19.
2023 Indiana Code › Title 27. Insurance › Article 1. Department of Insurance › Chapter 37.6. Program to Reduce or Eliminate Prior Authorization Requirements for Health Care Providers › 27-1-37.6-13. "Provider Organization"

Sec. 13. As used in this chapter, "provider organization" means an entity that serves beneficiaries on a risk basis through a network of employed or affiliated providers.
As added by P.L.203-2023, SEC.19.
2023 Indiana Code › Title 27. Insurance › Article 1. Department of Insurance › Chapter 37.6. Program to Reduce or Eliminate Prior Authorization Requirements for Health Care Providers › 27-1-37.6-14. "Same Health Care Service"

Sec. 14. For the purposes of this chapter, a health care service that is assigned a unique CPT code or combination of CPT codes to be used for the care of a patient with a specific diagnosis is the "same health care service" as another health care service that is assigned the same unique CPT code or combination of CPT codes to be used for the care of a patient with the same specific diagnosis.
As added by P.L.203-2023, SEC.19.
2023 Indiana Code › Title 27. Insurance › Article 1. Department of Insurance › Chapter 37.6. Program to Reduce or Eliminate Prior Authorization Requirements for Health Care Providers › 27-1-37.6-15. "Value Based Health Care Reimbursement Agreement"

Sec. 15. (a) As used in this chapter, "value based health care reimbursement agreement" may include the following:
(1) An accountable care organization that has a contract with a health plan in which the health plan:
(A) does not assume risk for prior authorization to a provider organization; or
(B) delegates risk to a provider organization to manage prior authorization.
(2) Bundled payments.
(3) A capitated rate reimbursement arrangement.
(4) A pay for performance arrangement.
(5) Any other health care reimbursement arrangement in which the health care provider accepts at most ten percent (10%) of the downside risk.
(b) The term does not include any of the following:
(1) Narrow networks.
(2) Fixed fee schedules.
As added by P.L.203-2023, SEC.19.
2023 Indiana Code › Title 27. Insurance › Article 1. Department of Insurance › Chapter 37.6. Program to Reduce or Eliminate Prior Authorization Requirements for Health Care Providers › 27-1-37.6-16. Program Eligibility

Sec. 16. A health care provider that enters into:
(1) a value based health care reimbursement agreement; and
(2) an electronic medical records access agreement;
with a health plan may qualify to participate in a program established by the health plan to reduce or eliminate prior authorization requirements.
As added by P.L.203-2023, SEC.19.
2023 Indiana Code › Title 27. Insurance › Article 1. Department of Insurance › Chapter 37.6. Program to Reduce or Eliminate Prior Authorization Requirements for Health Care Providers › 27-1-37.6-17. Notice of Participation Requirements

Sec. 17. (a) A health plan shall notify a health care provider of any requirements that a health care provider must meet to participate in a program under section 16 of this chapter.
(b) If a health plan determines that a health care provider is qualified to participate in a program established under section 16 of this chapter, the health plan shall send a notice to the health care provider that contains the following information:
(1) A statement that the health care provider qualifies to participate in the program.
(2) A list of each type of health care service that is subject to the elimination or reduction of prior authorization requirements under the program.
As added by P.L.203-2023, SEC.19.
2023 Indiana Code › Title 27. Insurance › Article 1. Department of Insurance › Chapter 37.6. Program to Reduce or Eliminate Prior Authorization Requirements for Health Care Providers › 27-1-37.6-18. Requiring Additional Information Concerning Health Care Services Rendered

Sec. 18. This chapter does not preclude a health plan from requiring a health care provider to provide additional information to the health plan about health care services rendered to the health plan's members.
As added by P.L.203-2023, SEC.19.
2023 Indiana Code › Title 27. Insurance › Article 1. Department of Insurance › Chapter 38. Regulation of Depository Institutions › 27-1-38-2. "Customer" Defined

Sec. 2. As used in this section, "customer" means an individual who purchases, applies to purchase, or is solicited to purchase insurance primarily for personal, family, or household purposes.
As added by P.L.130-2002, SEC.2.
2023 Indiana Code › Title 27. Insurance › Article 1. Department of Insurance › Chapter 38. Regulation of Depository Institutions › 27-1-38-3. "Depository Institution" Defined

Sec. 3. As used in this chapter, "depository institution" means a depository financial institution (as defined in IC 28-9-2-6).
As added by P.L.130-2002, SEC.2.
2023 Indiana Code › Title 27. Insurance › Article 1. Department of Insurance › Chapter 38. Regulation of Depository Institutions › 27-1-38-5. "Person That Sells, Solicits, Advertises, or Offers Insurance on Behalf of a Depository Institution" Defined

Sec. 5. As used in this chapter, "person that sells, solicits, advertises, or offers insurance on behalf of a depository institution" means a person to which one (1) of the following applies:
(1) The person represents to a customer that the sale, solicitation, advertisement, or offer of insurance is by or on behalf of the depository institution.
(2) The depository institution:
(A) refers a customer to the person; and
(B) has a contractual arrangement with the person to receive commissions or fees on sales of insurance that result from referrals to the person.
(3) Documents that provide evidence of the sale, solicitation, advertisement, or offer of insurance identify or refer to the depository institution.
As added by P.L.130-2002, SEC.2.
2023 Indiana Code › Title 27. Insurance › Article 1. Department of Insurance › Chapter 38. Regulation of Depository Institutions › 27-1-38-8. Required Disclosure Concerning Insurance Related to a Loan or a Credit Extension

Sec. 8. (a) A depository institution or the affiliate of a depository institution that:
(1) lends money or extends credit; and
(2) solicits insurance primarily for personal, family, or household purposes;
shall disclose in writing to a customer that the insurance related to the loan or credit extension may be purchased from an insurer or insurance producer chosen by the customer, subject only to the ability of the depository institution or affiliate to reasonably reject an insurer or insurance producer as described in section 7(4) of this chapter.
(b) A disclosure under subsection (a) must inform the customer that the customer's choice of insurer or insurance producer does not affect:
(1) the decision of the depository institution or the affiliate of a depository institution regarding the loan or credit extension; or
(2) the terms of the loan or credit extension;
except that the depository institution or the affiliate of a depository institution may impose reasonable requirements concerning the creditworthiness of the insurer and the scope of insurance coverage chosen, as described in section 7(4) of this chapter.
As added by P.L.130-2002, SEC.2.
2023 Indiana Code › Title 27. Insurance › Article 1. Department of Insurance › Chapter 38. Regulation of Depository Institutions › 27-1-38-9. Required Disclosures Before Sale of Insurance

Sec. 9. (a) This section applies as follows:
(1) To an affiliate of a depository institution only to the extent that the affiliate sells, solicits, advertises, or offers insurance at the office of a depository institution or on behalf of a depository institution.
(2) To the:
(A) sale of;
(B) solicitation for; or
(C) application for;
insurance by an individual primarily for personal, family, or household purposes and only to the extent that a disclosure is accurate.
(b) A depository institution or an affiliate of a depository institution that solicits, sells, advertises, or offers insurance, and a person that sells, solicits, advertises, or offers insurance on behalf of a depository institution, shall disclose to a customer, in writing where practicable, in a clear and conspicuous manner, and before a sale of insurance, that the insurance:
(1) is not a deposit;
(2) is not insured by the Federal Deposit Insurance Corporation or another federal government agency;
(3) is not guaranteed by the depository institution, the affiliate of a depository institution, or the person that sells, solicits, advertises, or offers insurance on behalf of a depository institution; and
(4) involves investment risk including possible loss of value, if appropriate.
As added by P.L.130-2002, SEC.2.
2023 Indiana Code › Title 27. Insurance › Article 1. Department of Insurance › Chapter 38. Regulation of Depository Institutions › 27-1-38-10. Acknowledgment of Receipt of Required Disclosure

Sec. 10. (a) A depository institution that solicits, sells, advertises, or offers insurance, a depository institution's affiliate that solicits, sells, advertises, or offers insurance, or a person that sells, solicits, advertises, or offers insurance on behalf of a depository institution shall obtain from a customer to whom a disclosure is made under section 9 of this chapter a written acknowledgment of receipt of the disclosure:
(1) when the customer receives the disclosure; or
(2) at the time of the initial purchase of the insurance.
(b) If a solicitation for insurance is conducted by telephone, the depository institution, the affiliate of a depository institution, or the person that sells, solicits, advertises, or offers insurance on behalf of a depository institution shall:
(1) obtain an oral acknowledgment of receipt of the disclosure;
(2) maintain documentation to show that the acknowledgment was given by the customer; and
(3) make reasonable efforts to obtain a written acknowledgment from the customer.
As added by P.L.130-2002, SEC.2.
2023 Indiana Code › Title 27. Insurance › Article 1. Department of Insurance › Chapter 38. Regulation of Depository Institutions › 27-1-38-11. Requirements for Electronic Disclosure

Sec. 11. If:
(1) a customer consents to receive the disclosure required under section 8 of this chapter electronically; and
(2) the disclosure is provided to the customer in a format that the customer may retain or obtain at a later time;
the depository institution, the affiliate of a depository institution, or the person that sells, solicits, advertises, or offers insurance on behalf of a depository institution may provide the disclosure electronically and may obtain from the customer acknowledgment of receipt of the disclosure electronically.
As added by P.L.130-2002, SEC.2.
2023 Indiana Code › Title 27. Insurance › Article 1. Department of Insurance › Chapter 38. Regulation of Depository Institutions › 27-1-38-12. Commissioner Examination and Investigation

Sec. 12. (a) The commissioner may examine and investigate the insurance activities of a person that the commissioner believes to be in violation of this chapter. A person examined or investigated under this section shall, upon reasonable notice from the commissioner, make the insurance related books and records of the person available to the commissioner.
(b) In the case of an examination or investigation of a depository institution under subsection (a), the commissioner shall, before performing the examination or investigation:
(1) notify the federal or state banking agency that regulates the depository institution that the commissioner intends to examine or investigate the depository institution; and
(2) advise the federal or state banking agency of the depository institution's suspected violation of this section.
As added by P.L.130-2002, SEC.2.
2023 Indiana Code › Title 27. Insurance › Article 1. Department of Insurance › Chapter 38. Regulation of Depository Institutions › 27-1-38-13. Allowed Activities

Sec. 13. This chapter does not prevent a depository institution or an affiliate of a depository institution that lends money or extends credit from placing insurance on real or personal property if a customer fails to provide insurance that is required under terms of a loan agreement or credit agreement.
As added by P.L.130-2002, SEC.2.
2023 Indiana Code › Title 27. Insurance › Article 1. Department of Insurance › Chapter 38. Regulation of Depository Institutions › 27-1-38-14. Violation of Chapter

Sec. 14. A person that violates this chapter commits an unfair and deceptive act or practice in the business of insurance under IC 27-4-1-4.
As added by P.L.130-2002, SEC.2.
2023 Indiana Code › Title 27. Insurance › Article 1. Department of Insurance › Chapter 39. Independent Educational Institution Self-Insurance Consortium › 27-1-39-4. "Independent Postsecondary Educational Institution" Defined

Sec. 4. As used in this chapter, "independent postsecondary educational institution" refers to an independent, degree granting college or university that is:
(1) accredited by the Higher Learning Commission of the North Central Association of Colleges and Schools;
(2) chartered in Indiana; and
(3) operated as a nonprofit entity under Section 501(c)(3) of the Internal Revenue Code.
As added by P.L.38-2006, SEC.1. Amended by P.L.2-2007, SEC.352.