CHAPTER 36.2. PROVIDER PAYMENT
IC 27-13-36.2
Chapter 36.2. Provider Payment
IC 27-13-36.2-1
"Clean claim" defined
Sec. 1. As used in this chapter, "clean claim" means a claimsubmitted by a provider for payment for health care servicesprovided to an enrollee that has no defect, impropriety, or particularcircumstance requiring special treatment preventing payment.
As added by P.L.162-2001, SEC.6.
IC 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 healthmaintenance organization; and
(2) a limited service health maintenance organization.
As added by P.L.162-2001, SEC.6.
IC 27-13-36.2-3
Notice of deficiencies in claims
Sec. 3. (a) A health maintenance organization shall pay or denyeach clean claim in accordance with section 4 of this chapter.
(b) A health maintenance organization shall notify a provider ofany 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 aprovider as required under subsection (b) establishes the submittedclaim as a clean claim.
As added by P.L.162-2001, SEC.6. Amended by P.L.137-2002,SEC.3.
IC 27-13-36.2-4
Payment or denial of claims; interest
Sec. 4. (a) A health maintenance organization shall pay or denyeach 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 healthmaintenance 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 healthmaintenance 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 theclaim;
the health maintenance organization shall pay the provider thatsubmitted the claim interest on the lesser of the usual, customary, andreasonable charge for the health care services provided to theenrollee or an amount agreed to between the health maintenanceorganization 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 filedunder subsection (a)(1); or
(B) forty-six (46) days after the date the claim is filed undersubsection (a)(2); and
(2) stops accruing on the date the claim is paid.
(d) In paying interest under subsection (b), a health maintenanceorganization shall use the same interest rate as provided inIC 12-15-21-3(7)(A).
As added by P.L.162-2001, SEC.6. Amended by P.L.137-2002,SEC.4.
IC 27-13-36.2-5
Permitted forms
Sec. 5. A provider shall submit only the following forms forpayment by a health maintenance organization:
(1) HCFA-1500.
(2) HCFA-1450 (UB-92).
(3) American Dental Association (ADA) claim form.
As added by P.L.162-2001, SEC.6.
IC 27-13-36.2-6
Civil penalties
Sec. 6. (a) If the commissioner finds that a health maintenanceorganization has failed during any calendar year to process and payclean claims in compliance with this chapter, the commissioner mayassess an aggregate civil penalty against the health maintenanceorganization according to the following schedule:
(1) If the health maintenance organization has paid at leasteighty-five percent (85%) but less than ninety-five percent(95%) of all clean claims received from all providers during thecalendar year in compliance with this chapter, a civil penalty ofup to ten thousand dollars ($10,000).
(2) If the health maintenance organization has paid at least sixtypercent (60%) but less than eighty-five percent (85%) of allclean claims received from all providers during the calendaryear in compliance with this chapter, a civil penalty of at leastten thousand dollars ($10,000) but not more than one hundredthousand dollars ($100,000).
(3) If the health maintenance organization has paid less thansixty percent (60%) of all clean claims received from all
providers during the calendar year in compliance with thischapter, 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 maintenanceorganization's failure to achieve the standards established by thischapter is due to circumstances beyond the health maintenanceorganization's control.
(c) A health maintenance organization may contest a civil penaltyimposed under this section by requesting an administrative hearingunder IC 4-21.5 not more than thirty (30) days after the healthmaintenance organization receives notice of the assessment of thefine.
(d) If the commissioner imposes a civil penalty under this section,the commissioner may not impose a penalty against the healthmaintenance organization under IC 27-4-1 for the same activity.
(e) Civil penalties collected under this section shall be depositedin the state general fund.
As added by P.L.162-2001, SEC.6.
IC 27-13-36.2-7
Repealed
(Repealed by P.L.1-2007, SEC.248.)
IC 27-13-36.2-8
Claim payment errors
Sec. 8. (a) A health maintenance organization may not, more thantwo (2) years after the date on which an overpayment on a providerclaim was made to the provider by the health maintenanceorganization:
(1) request that the provider repay the overpayment; or
(2) adjust a subsequent claim filed by the provider as a methodof obtaining reimbursement of the overpayment from theprovider.
(b) A health maintenance organization may not be required tocorrect a payment error to a provider more than two (2) years afterthe date on which a payment on a provider claim was made to theprovider 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 tothe claim on which the overpayment or underpayment was made.
As added by P.L.55-2006, SEC.3.
IC 27-13-36.2-9
Claim overpayment adjustment
Sec. 9. Every subsequent claim that is adjusted by a healthmaintenance organization for reimbursement on an overpayment ofa previous provider claim made to the provider must be accompaniedby 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 theamount overpaid; and
(2) the amount of the overpayment that is being reimbursed tothe health maintenance organization through the adjustedsubsequent claim.
As added by P.L.55-2006, SEC.4.