IC 27-8-11
    Chapter 11. Accident and Sickness Insurance.ReimbursementAgreements

IC 27-8-11-1
Definitions
    Sec. 1. (a) The definitions in this section apply throughout thischapter.
    (b) "Credentialing" means a process through which an insurermakes a determination:
        (1) based on criteria established by the insurer; and
        (2) concerning whether a provider is eligible to:
            (A) provide health care services to an insured; and
            (B) receive reimbursement for the health care services;
        under an agreement entered into between the provider and theinsurer under section 3 of this chapter.
    (c) "Health care services":
        (1) means health care related services or products rendered orsold by a provider within the scope of the provider's license orlegal authorization; and
        (2) includes hospital, medical, surgical, dental, vision, andpharmaceutical services or products.
    (d) "Insured" means an individual entitled to reimbursement forexpenses of health care services under a policy issued oradministered by an insurer.
    (e) "Insurer" means an insurance company authorized in this stateto issue policies that provide reimbursement for expenses of healthcare services.
    (f) "Person" means an individual, an agency, a politicalsubdivision, a partnership, a corporation, an association, or any otherentity.
    (g) "Preferred provider plan" means an undertaking to enter intoagreements with providers relating to terms and conditions ofreimbursements for the health care services of insureds, members, orenrollees relating to the amounts to be charged to insureds, members,or enrollees for health care services.
    (h) "Provider" means an individual or entity duly licensed orlegally authorized to provide health care services.
As added by P.L.140-1984, SEC.1. Amended by P.L.31-1988,SEC.22; P.L.26-2005, SEC.1.

IC 27-8-11-2
Conflicting provisions
    Sec. 2. To the extent of any conflict between this chapter andIC 27-4-1-4, IC 27-8-5-15, IC 27-8-6-1, or any other statutoryprovision, this chapter prevails over the conflicting provision.Agreements may be entered into under section 3(a)(1) of this chapternotwithstanding any contradictory policy provision prescribed underIC 27-8-5-3(a)(9).
As added by P.L.140-1984, SEC.1. Amended by P.L.1-2010,

SEC.111.

IC 27-8-11-3
Reimbursement agreements; immunity
    Sec. 3. (a) An insurer may:
        (1) enter into agreements with providers relating to terms andconditions of reimbursement for health care services that maybe rendered to insureds of the insurer, including agreementsrelating to the amounts to be charged the insured for servicesrendered or the terms and conditions for activities intended toreduce inappropriate care;
        (2) issue or administer policies in this state that includeincentives for the insured to utilize the services of a providerthat has entered into an agreement with the insurer undersubdivision (1); and
        (3) issue or administer policies in this state that provide forreimbursement for expenses of health care services only if theservices have been rendered by a provider that has entered intoan agreement with the insurer under subdivision (1).
    (b) Before entering into any agreement under subsection (a)(1), aninsurer shall establish terms and conditions that must be met byproviders wishing to enter into an agreement with the insurer undersubsection (a)(1). These terms and conditions may not discriminateunreasonably against or among providers. For the purposes of thissubsection, neither differences in prices among hospitals or otherinstitutional providers produced by a process of individualnegotiation nor price differences among other providers in differentgeographical areas or different specialties constitutes unreasonablediscrimination. Upon request by a provider seeking to enter into anagreement with an insurer under subsection (a)(1), the insurer shallmake available to the provider a written statement of the terms andconditions that must be met by providers wishing to enter into anagreement with the insurer under subsection (a)(1).
    (c) No hospital, physician, pharmacist, or other providerdesignated in IC 27-8-6-1 willing to meet the terms and conditions ofagreements described in this section may be denied the right to enterinto an agreement under subsection (a)(1). When an insurer deniesa provider the right to enter into an agreement with the insurer undersubsection (a)(1) on the grounds that the provider does not satisfy theterms and conditions established by the insurer for providers enteringinto agreements with the insurer, the insurer shall provide theprovider with a written notice that:
        (1) explains the basis of the insurer's denial; and
        (2) states the specific terms and conditions that the provider, inthe opinion of the insurer, does not satisfy.
    (d) In no event may an insurer deny or limit reimbursement to aninsured under this chapter on the grounds that the insured was notreferred to the provider by a person acting on behalf of or under anagreement with the insurer.
    (e) No cause of action shall arise against any person or insurer for:        (1) disclosing information as required by this section; or
        (2) the subsequent use of the information by unauthorizedindividuals.
Nor shall such a cause of action arise against any person or providerfor furnishing personal or privileged information to an insurer.However, this subsection provides no immunity for disclosing orfurnishing false information with malice or willful intent to injureany person, provider, or insurer.
    (f) Nothing in this chapter abrogates the privileges and immunitiesestablished in IC 34-30-15 (or IC 34-4-12.6 before its repeal).
As added by P.L.140-1984, SEC.1. Amended by P.L.134-1994,SEC.1; P.L.191-1996, SEC.1; P.L.1-1998, SEC.151; P.L.1-1999,SEC.59.

IC 27-8-11-3.1
Repealed
    (Repealed by P.L.1-1999, SEC.60.)

IC 27-8-11-4
Accessibility and availability terms; reasonable standards
    Sec. 4. Policies issued under section 3(a)(3) or section 3.1 of thischapter (before its repeal) may not contain terms or conditions thatwould operate unreasonably to restrict the access and availability ofhealth care services for the insured. The commissioner of insurancemay, under IC 4-22-2, adopt rules binding upon insurers prescribingreasonable standards relating to the accessibility and availability ofhealth care services for persons insured under policies described insection 3(a)(3) or section 3.1 of this chapter (before its repeal).
As added by P.L.140-1984, SEC.1. Amended by P.L.134-1994,SEC.3; P.L.1-1999, SEC.61.

IC 27-8-11-4.5
Permitted disclosures by providers; coverage of benefit or service;payment of provider; application
    Sec. 4.5. (a) An agreement between an insurer and provider undersection 3 of this chapter may not prohibit a provider from disclosing:
        (1) financial incentives to the provider;
        (2) all treatment options available to an insured, including thosenot covered by the insured's policy.
    (b) An insurer may not penalize a provider financially or in anyother manner for making a disclosure permitted under subsection (a).
    (c) An insured is not entitled to coverage of a benefit or serviceunder a health insurance policy unless that benefit or service isincluded in the insured's health insurance policy.
    (d) A provider is not entitled to payment under a policy forbenefits or services provided to an insured unless the provider has acontract or an agreement with the insurer.
    (e) This section applies to a contract entered, renewed, ormodified after June 30, 1996.
As added by P.L.192-1996, SEC.1.
IC 27-8-11-5
Preferred provider plans; filing sworn statement
    Sec. 5. Each person that organizes a preferred provider plan underthis chapter shall file with the commissioner before March 1 of eachyear a statement, under oath, upon a form prescribed by thecommissioner that covers the preceding calendar year and includesthe following:
        (1) The name and address of each person that has organized apreferred provider plan.
        (2) The names and addresses of the providers with whom thepreferred provider plan has entered into agreements undersection 3 of this chapter.
        (3) The geographical area, by counties, within which thepreferred provider plan provides or arranges for health careservices for insureds, members or enrollees.
        (4) The number of insureds, members or enrollees covered bythe agreements listed in subdivision (2).
As added by P.L.31-1988, SEC.23.

IC 27-8-11-6
Preferred provider plans; hospital accreditation
    Sec. 6. (a) A preferred provider plan may not refuse to enter intoan agreement with a hospital solely because the hospital has notobtained accreditation from an accreditation organization that:
        (1) establishes standards for the organization and operation ofhospitals;
        (2) requires the hospital to undergo a survey process for a feepaid by the hospital; and
        (3) was organized and formed in 1951.
    (b) This section does not prohibit a preferred provider plan fromusing performance indicators or quality standards that:
        (1) are developed by private organizations; and
        (2) do not rely upon a survey process for a fee charged to thehospital to evaluate performance.
As added by P.L.259-1995, SEC.2.

IC 27-8-11-7
Provider credentialing
    Sec. 7. (a) This section applies to an insurer that issues oradministers a policy that provides coverage for basic health careservices (as defined in IC 27-13-1-4).
    (b) The department of insurance shall prescribe the credentialingapplication form used by the Council for Affordable QualityHealthcare (CAQH) in electronic or paper format, which must beused by:
        (1) a provider who applies for credentialing by an insurer; and
        (2) an insurer that performs credentialing activities.
    (c) An insurer shall notify a provider concerning a deficiency ona completed credentialing application form submitted by the providernot later than thirty (30) business days after the insurer receives the

completed credentialing application form.
    (d) An insurer shall notify a provider concerning the status of theprovider's completed credentialing application not later than:
        (1) sixty (60) days after the insurer receives the completedcredentialing application form; and
        (2) every thirty (30) days after the notice is provided undersubdivision (1), until the insurer makes a final credentialingdetermination concerning the provider.
As added by P.L.26-2005, SEC.2.

IC 27-8-11-8
Provider directories
    Sec. 8. (a) An insurer may provide to an insured in electronic orpaper form a directory of providers with which the insurer hasentered into an agreement under section 3 of this chapter.
    (b) An insurer that provides a directory described in subsection (a)shall:
        (1) inform the insured that the insured may request the directoryin paper form; and
        (2) provide the directory in paper form upon the request of theinsured.
As added by P.L.125-2005, SEC.5.

IC 27-8-11-9
Preferred provider agreement prohibitions
    Sec. 9. (a) As used in this section, "insurer" includes thefollowing:
        (1) An administrator licensed under IC 27-1-25.
        (2) A person that pays or administers claims on behalf of aninsurer.
    (b) An agreement between an insurer and a provider under thischapter may not contain a provision that:
        (1) prohibits, or grants the insurer an option to prohibit, theprovider from contracting with another insurer to accept lowerpayment for health care services than the payment specified inthe agreement;
        (2) requires, or grants the insurer an option to require, theprovider to accept a lower payment from the insurer if theprovider agrees with another insurer to accept lower paymentfor health care services;
        (3) requires, or grants the insurer an option of, termination orrenegotiation of the agreement if the provider agrees withanother insurer to accept lower payment for health careservices; or
        (4) requires the provider to disclose the provider'sreimbursement rates under contracts with other insurers.
    (c) A provision that:
        (1) is contained in an agreement between an insurer and aprovider under this chapter; and
        (2) violates this section;is void.
As added by P.L.74-2007, SEC.1.

IC 27-8-11-10
Coverage for dialysis treatment
    Sec. 10. (a) As used in this section, "dialysis facility" means anoutpatient facility in Indiana at which a dialysis treatment providerprovides dialysis treatment.
    (b) As used in this section, "contracted dialysis facility" means adialysis facility that has entered into an agreement with a particularinsurer under section 3 of this chapter.
    (c) Notwithstanding section 1 of this chapter, as used in thissection, "insured" refers only to an insured who requires dialysistreatment.
    (d) As used in this section, "insurer" includes the following:
        (1) An administrator licensed under IC 27-1-25.
        (2) An agent of an insurer.
    (e) As used in this section, "non-contracted dialysis facility"means a dialysis facility that has not entered into an agreement witha particular insurer under section 3 of this chapter.
    (f) An insurer shall not require an insured, as a condition ofcoverage or reimbursement, to:
        (1) if the nearest dialysis facility is located within thirty (30)miles of the insured's home, travel more than thirty (30) milesfrom the insured's home to obtain dialysis treatment; or
        (2) if the nearest dialysis facility is located more than thirty (30)miles from the insured's home, travel a greater distance than thedistance to the nearest dialysis facility to obtain dialysistreatment;
regardless of whether the insured chooses to receive dialysistreatment at a contracted dialysis facility or a non-contracted dialysisfacility.
As added by P.L.111-2008, SEC.4.

IC 27-8-11-11
Insurer payment to insured for service rendered by noncontractedprovider; requirements
    Sec. 11. (a) As used in this section, "noncontracted provider"means a provider that has not entered into an agreement with aninsurer under section 3 of this chapter.
    (b) After September 30, 2009, if an insurer makes a payment to aninsured for a health care service rendered by a noncontractedprovider, the insurer shall include with the payment instrumentwritten notice to the insured that includes the following:
        (1) A statement specifying the claims covered by the paymentinstrument.
        (2) The name and address of the provider submitting eachclaim.
        (3) The amount paid by the insurer for each claim.
        (4) Any amount of a claim that is the insured's responsibility.        (5) A statement in at least 24 point bold type that:
            (A) instructs the insured to use the payment to pay thenoncontracted provider if the insured has not paid thenoncontracted provider in full;
            (B) specifies that paying the noncontracted provider is theinsured's responsibility; and
            (C) states that the failure to make the payment violates thelaw and may result in collection proceedings or criminalpenalties.
As added by P.L.144-2009, SEC.2.