IC 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.
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 health
maintenance 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 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.
IC 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.
IC 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) 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 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.
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 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.
IC 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.
IC 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.
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 health
maintenance 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 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.
IC 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.
IC 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) 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 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.
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 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.
IC 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.
IC 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.
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 health
maintenance 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 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.
IC 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.
IC 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) 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 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.
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 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.
IC 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.
