IC 27-13-9
Chapter 9. Information to Enrollees or Subscribers
IC 27-13-9-1 List of providers
Sec. 1. (a) Upon:
(1) the enrollment; and
(2) each reenrollment;
of a subscriber, a health maintenance organization must provide to
the subscriber in electronic or paper form a list of providers who
provide health care services through the health maintenance
organization. The health maintenance organization must also provide
the list of providers in electronic or paper form to a potential enrollee
upon request.
(b) A health maintenance organization shall:
(1) inform a subscriber or potential enrollee that the subscriber
or potential enrollee may request a list described in subsection
(a) in paper form; and
(2) provide the list in paper form upon the request of the
subscriber or potential enrollee. As added by P.L.26-1994, SEC.25. Amended by P.L.69-1998, SEC.7;
P.L.125-2005, SEC.7.
IC 27-13-9-2 Notice of change in operation of health maintenance organization
Sec. 2. Not more than thirty (30) days after any material change
in the operation of a health maintenance organization that will
directly affect the subscribers or enrollees of the organization, the
health maintenance organization shall provide notice of the change
to the subscribers or enrollees affected by the change. As added by P.L.26-1994, SEC.25.
IC 27-13-9-3 Termination of provider
Sec. 3. (a) A health maintenance organization shall notify an
enrollee in writing of the termination of:
(1) the provider who currently provides primary health care
services to that enrollee;
(2) any other participating provider seen by the enrollee during
the previous year; and
(3) a hospital.
(b) After the termination of the provider who provided primary
health care services to an enrollee, the health maintenance
organization shall assist the enrollee in transferring to another
participating primary care provider.
(c) If a health maintenance organization notifies an enrollee of the
termination of a hospital, the notice must include the names of all
participating providers employed by the hospital. As added by P.L.26-1994, SEC.25. Amended by P.L.133-1999,
SEC.3; P.L.196-2001, SEC.2. IC 27-13-9-4 Information on services and filing grievances; telephone number
Sec. 4. A health maintenance organization shall provide to each
enrollee and subscriber:
(1) information on:
(A) how services can be obtained;
(B) where additional information on access to services can
be obtained;
(C) how to file a grievance under IC 27-13-10 and
IC 27-13-10.1;
(D) the health maintenance organization's:
(i) structure;
(ii) health care benefits and exclusions; and
(iii) criteria for denying coverage; and
(E) costs for which the enrollee or subscriber is responsible;
and
(2) a toll free telephone number through which the enrollee can
contact the health maintenance organization at no cost to the
enrollee to obtain information and to file grievances.
The information under this section must be provided to a potential
enrollee of the health maintenance organization upon request. As added by P.L.26-1994, SEC.25. Amended by P.L.191-1997,
SEC.3; P.L.69-1998, SEC.8; P.L.133-1999, SEC.4.
IC 27-13-9-5 Prescription drug information card
Sec. 5. (a) This section applies to a health maintenance
organization that provides coverage for prescription drugs or devices
and issues a card or other technology for claims processing.
(b) The card or other technology issued by a health maintenance
organization must contain uniform prescription drug information that
complies with the requirements established under subsection (c).
(c) Prescription drug information cards or other technology must
meet either of the following criteria:
(1) Be in a format and contain information fields approved by
the National Council for Prescription Drug Programs (NCPDP)
as contained in the National Council for Prescription Drug
Programs Pharmacy ID Card Implementation Guide in effect on
the October 1 most immediately preceding the issuance of the
card.
(2) Contain the following information:
(A) The health benefit plan's name.
(B) The enrollee's name, group number, and identification
number.
(C) A telephone number to inquire about pharmacy related
issues.
(D) The issuer's international identification number or ANSI
BIN number, labeled as RxBIN.
(E) The processor control number, labeled as RxPCN.
(F) The insured's pharmacy benefits group number if
different than medical group number, labeled as RxGRP.
Only those fields listed in clauses (A) through (F) that are
required for proper adjudication of the claim must appear on the
card. If the card is used to adjudicate non-pharmacy claims,
then the designation "Rx" listed in clauses (D) through (F) is
not required to be used by the issuer.
(d) A health maintenance organization may not be required to
issue a prescription drug information card or other technology to a
person more than one (1) time during a twelve (12) month period.
(e) The prescription drug information cards or other technology
issued under this section may be used for health care service
coverage other than the coverage to which this chapter applies. As added by P.L.230-2001, SEC.3. Amended by P.L.1-2002,
SEC.123.
IC 27-13-9
Chapter 9. Information to Enrollees or Subscribers
IC 27-13-9-1 List of providers
Sec. 1. (a) Upon:
(1) the enrollment; and
(2) each reenrollment;
of a subscriber, a health maintenance organization must provide to
the subscriber in electronic or paper form a list of providers who
provide health care services through the health maintenance
organization. The health maintenance organization must also provide
the list of providers in electronic or paper form to a potential enrollee
upon request.
(b) A health maintenance organization shall:
(1) inform a subscriber or potential enrollee that the subscriber
or potential enrollee may request a list described in subsection
(a) in paper form; and
(2) provide the list in paper form upon the request of the
subscriber or potential enrollee. As added by P.L.26-1994, SEC.25. Amended by P.L.69-1998, SEC.7;
P.L.125-2005, SEC.7.
IC 27-13-9-2 Notice of change in operation of health maintenance organization
Sec. 2. Not more than thirty (30) days after any material change
in the operation of a health maintenance organization that will
directly affect the subscribers or enrollees of the organization, the
health maintenance organization shall provide notice of the change
to the subscribers or enrollees affected by the change. As added by P.L.26-1994, SEC.25.
IC 27-13-9-3 Termination of provider
Sec. 3. (a) A health maintenance organization shall notify an
enrollee in writing of the termination of:
(1) the provider who currently provides primary health care
services to that enrollee;
(2) any other participating provider seen by the enrollee during
the previous year; and
(3) a hospital.
(b) After the termination of the provider who provided primary
health care services to an enrollee, the health maintenance
organization shall assist the enrollee in transferring to another
participating primary care provider.
(c) If a health maintenance organization notifies an enrollee of the
termination of a hospital, the notice must include the names of all
participating providers employed by the hospital. As added by P.L.26-1994, SEC.25. Amended by P.L.133-1999,
SEC.3; P.L.196-2001, SEC.2. IC 27-13-9-4 Information on services and filing grievances; telephone number
Sec. 4. A health maintenance organization shall provide to each
enrollee and subscriber:
(1) information on:
(A) how services can be obtained;
(B) where additional information on access to services can
be obtained;
(C) how to file a grievance under IC 27-13-10 and
IC 27-13-10.1;
(D) the health maintenance organization's:
(i) structure;
(ii) health care benefits and exclusions; and
(iii) criteria for denying coverage; and
(E) costs for which the enrollee or subscriber is responsible;
and
(2) a toll free telephone number through which the enrollee can
contact the health maintenance organization at no cost to the
enrollee to obtain information and to file grievances.
The information under this section must be provided to a potential
enrollee of the health maintenance organization upon request. As added by P.L.26-1994, SEC.25. Amended by P.L.191-1997,
SEC.3; P.L.69-1998, SEC.8; P.L.133-1999, SEC.4.
IC 27-13-9-5 Prescription drug information card
Sec. 5. (a) This section applies to a health maintenance
organization that provides coverage for prescription drugs or devices
and issues a card or other technology for claims processing.
(b) The card or other technology issued by a health maintenance
organization must contain uniform prescription drug information that
complies with the requirements established under subsection (c).
(c) Prescription drug information cards or other technology must
meet either of the following criteria:
(1) Be in a format and contain information fields approved by
the National Council for Prescription Drug Programs (NCPDP)
as contained in the National Council for Prescription Drug
Programs Pharmacy ID Card Implementation Guide in effect on
the October 1 most immediately preceding the issuance of the
card.
(2) Contain the following information:
(A) The health benefit plan's name.
(B) The enrollee's name, group number, and identification
number.
(C) A telephone number to inquire about pharmacy related
issues.
(D) The issuer's international identification number or ANSI
BIN number, labeled as RxBIN.
(E) The processor control number, labeled as RxPCN.
(F) The insured's pharmacy benefits group number if
different than medical group number, labeled as RxGRP.
Only those fields listed in clauses (A) through (F) that are
required for proper adjudication of the claim must appear on the
card. If the card is used to adjudicate non-pharmacy claims,
then the designation "Rx" listed in clauses (D) through (F) is
not required to be used by the issuer.
(d) A health maintenance organization may not be required to
issue a prescription drug information card or other technology to a
person more than one (1) time during a twelve (12) month period.
(e) The prescription drug information cards or other technology
issued under this section may be used for health care service
coverage other than the coverage to which this chapter applies. As added by P.L.230-2001, SEC.3. Amended by P.L.1-2002,
SEC.123.
IC 27-13-9
Chapter 9. Information to Enrollees or Subscribers
IC 27-13-9-1 List of providers
Sec. 1. (a) Upon:
(1) the enrollment; and
(2) each reenrollment;
of a subscriber, a health maintenance organization must provide to
the subscriber in electronic or paper form a list of providers who
provide health care services through the health maintenance
organization. The health maintenance organization must also provide
the list of providers in electronic or paper form to a potential enrollee
upon request.
(b) A health maintenance organization shall:
(1) inform a subscriber or potential enrollee that the subscriber
or potential enrollee may request a list described in subsection
(a) in paper form; and
(2) provide the list in paper form upon the request of the
subscriber or potential enrollee. As added by P.L.26-1994, SEC.25. Amended by P.L.69-1998, SEC.7;
P.L.125-2005, SEC.7.
IC 27-13-9-2 Notice of change in operation of health maintenance organization
Sec. 2. Not more than thirty (30) days after any material change
in the operation of a health maintenance organization that will
directly affect the subscribers or enrollees of the organization, the
health maintenance organization shall provide notice of the change
to the subscribers or enrollees affected by the change. As added by P.L.26-1994, SEC.25.
IC 27-13-9-3 Termination of provider
Sec. 3. (a) A health maintenance organization shall notify an
enrollee in writing of the termination of:
(1) the provider who currently provides primary health care
services to that enrollee;
(2) any other participating provider seen by the enrollee during
the previous year; and
(3) a hospital.
(b) After the termination of the provider who provided primary
health care services to an enrollee, the health maintenance
organization shall assist the enrollee in transferring to another
participating primary care provider.
(c) If a health maintenance organization notifies an enrollee of the
termination of a hospital, the notice must include the names of all
participating providers employed by the hospital. As added by P.L.26-1994, SEC.25. Amended by P.L.133-1999,
SEC.3; P.L.196-2001, SEC.2. IC 27-13-9-4 Information on services and filing grievances; telephone number
Sec. 4. A health maintenance organization shall provide to each
enrollee and subscriber:
(1) information on:
(A) how services can be obtained;
(B) where additional information on access to services can
be obtained;
(C) how to file a grievance under IC 27-13-10 and
IC 27-13-10.1;
(D) the health maintenance organization's:
(i) structure;
(ii) health care benefits and exclusions; and
(iii) criteria for denying coverage; and
(E) costs for which the enrollee or subscriber is responsible;
and
(2) a toll free telephone number through which the enrollee can
contact the health maintenance organization at no cost to the
enrollee to obtain information and to file grievances.
The information under this section must be provided to a potential
enrollee of the health maintenance organization upon request. As added by P.L.26-1994, SEC.25. Amended by P.L.191-1997,
SEC.3; P.L.69-1998, SEC.8; P.L.133-1999, SEC.4.
IC 27-13-9-5 Prescription drug information card
Sec. 5. (a) This section applies to a health maintenance
organization that provides coverage for prescription drugs or devices
and issues a card or other technology for claims processing.
(b) The card or other technology issued by a health maintenance
organization must contain uniform prescription drug information that
complies with the requirements established under subsection (c).
(c) Prescription drug information cards or other technology must
meet either of the following criteria:
(1) Be in a format and contain information fields approved by
the National Council for Prescription Drug Programs (NCPDP)
as contained in the National Council for Prescription Drug
Programs Pharmacy ID Card Implementation Guide in effect on
the October 1 most immediately preceding the issuance of the
card.
(2) Contain the following information:
(A) The health benefit plan's name.
(B) The enrollee's name, group number, and identification
number.
(C) A telephone number to inquire about pharmacy related
issues.
(D) The issuer's international identification number or ANSI
BIN number, labeled as RxBIN.
(E) The processor control number, labeled as RxPCN.
(F) The insured's pharmacy benefits group number if
different than medical group number, labeled as RxGRP.
Only those fields listed in clauses (A) through (F) that are
required for proper adjudication of the claim must appear on the
card. If the card is used to adjudicate non-pharmacy claims,
then the designation "Rx" listed in clauses (D) through (F) is
not required to be used by the issuer.
(d) A health maintenance organization may not be required to
issue a prescription drug information card or other technology to a
person more than one (1) time during a twelve (12) month period.
(e) The prescription drug information cards or other technology
issued under this section may be used for health care service
coverage other than the coverage to which this chapter applies. As added by P.L.230-2001, SEC.3. Amended by P.L.1-2002,
SEC.123.
