IC 27-8-5.7
    Chapter 5.7. Accident and Sickness Insurance; Provider Payment

IC 27-8-5.7-1
"Accident and sickness insurance policy" defined
    Sec. 1. As used in this chapter, "accident and sickness insurancepolicy" has the meaning set forth in IC 27-8-5-1.
As added by P.L.162-2001, SEC.5.

IC 27-8-5.7-2
"Clean claim" defined
    Sec. 2. As used in this chapter, "clean claim" means a claimsubmitted by a provider for payment under an accident and sicknessinsurance policy issued in Indiana that has no defect, impropriety, orparticular circumstance requiring special treatment preventingpayment.
As added by P.L.162-2001, SEC.5.

IC 27-8-5.7-3
"Insurer" defined
    Sec. 3. As used in this chapter, "insurer" means an insurancecompany issued a certificate of authority in Indiana to issue accidentand sickness insurance policies. The term includes:
        (1) a preferred provider plan (as defined in IC 27-8-11-1); and
        (2) an insurance administrator that:
            (A) collects charges or premiums; and
            (B) adjusts or settles claims;
in connection with coverage under an accident and sicknessinsurance policy.
As added by P.L.162-2001, SEC.5.

IC 27-8-5.7-4
"Provider" defined
    Sec. 4. As used in this chapter, "provider" has the meaning setforth in IC 27-8-11-1.
As added by P.L.162-2001, SEC.5.

IC 27-8-5.7-5
Notice of deficiencies in claims
    Sec. 5. (a) An insurer shall pay or deny each clean claim inaccordance with section 6 of this chapter.
    (b) An insurer shall notify a provider of any deficiencies in asubmitted 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 an insurer to notify a provider as required undersubsection (b) establishes the submitted claim as a clean claim.
As added by P.L.162-2001, SEC.5. Amended by P.L.137-2002,SEC.2.
IC 27-8-5.7-6
Payment or denial of claims; interest
    Sec. 6. (a) An insurer shall pay or deny each clean claim asfollows:
        (1) If the claim is filed electronically, within thirty (30) daysafter the date the claim is received by the insurer.
        (2) If the claim is filed on paper, within forty-five (45) daysafter the date the claim is received by the insurer.
    (b) If:
        (1) an insurer fails to pay or deny a clean claim in the timerequired under subsection (a); and
        (2) the insurer subsequently pays the claim;
the insurer shall pay the provider that submitted the claim interest onthe accident and sickness insurance policy allowable amount of theclaim 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), an insurer shall use thesame interest rate as provided in IC 12-15-21-3(7)(A).
As added by P.L.162-2001, SEC.5.

IC 27-8-5.7-7
Permitted forms
    Sec. 7. A provider shall submit only the following forms forpayment by an insurer:
        (1) HCFA-1500.
        (2) HCFA-1450 (UB-92).
        (3) American Dental Association (ADA) claim form.
As added by P.L.162-2001, SEC.5.

IC 27-8-5.7-8
Civil penalties
    Sec. 8. (a) If the commissioner finds that an insurer has failedduring any calendar year to process and pay clean claims incompliance with this chapter, the commissioner may assess anaggregate civil penalty against the insurer according to the followingschedule:
        (1) If the insurer has paid at least eighty-five percent (85%) butless than ninety-five percent (95%) of all clean claims receivedfrom all providers during the calendar year in compliance withthis chapter, a civil penalty of up to ten thousand dollars($10,000).
        (2) If the insurer has paid at least sixty percent (60%) but lessthan eighty-five percent (85%) of all clean claims received fromall 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 insurer has paid less than sixty percent (60%) of allclean claims received from all providers during the calendaryear in compliance with this chapter, a civil penalty of at leastone hundred thousand dollars ($100,000) but not more than twohundred thousand dollars ($200,000).
    (b) In determining the amount of a civil penalty under this section,the commissioner shall consider whether the insurer's failure toachieve the standards established by this chapter is due tocircumstances beyond the insurer's control.
    (c) An insurer may contest a civil penalty imposed under thissection by requesting an administrative hearing under IC 4-21.5 notmore than thirty (30) days after the insurer receives notice of theassessment of the fine.
    (d) If the commissioner imposes a civil penalty under this section,the commissioner may not impose a penalty against the insurer underIC 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.5.

IC 27-8-5.7-9
Repealed
    (Repealed by P.L.1-2007, SEC.248.)

IC 27-8-5.7-10
Claim payment errors
    Sec. 10. (a) An insurer may not, more than two (2) years after thedate on which an overpayment on a provider claim was made to theprovider by the insurer:
        (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) An insurer may not be required to correct a payment error toa provider more than two (2) years after the date on which a paymenton a provider claim was made to the provider by the insurer.
    (c) This section does not apply in cases of fraud by the provider,the insured, or the insurer with respect to the claim on which theoverpayment or underpayment was made.
As added by P.L.55-2006, SEC.1.

IC 27-8-5.7-11
Claim overpayment adjustment
    Sec. 11. Every subsequent claim that is adjusted by an insurer forreimbursement on an overpayment of a previous provider claim madeto the provider must be accompanied by an explanation of the reasonfor 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 theoverpaid amount; and
        (2) the amount of the overpayment that is being reimbursed tothe insurer through the adjusted subsequent claim.
As added by P.L.55-2006, SEC.2.