Ind. Code ch. 27-8-5.7

Ind. Code ch. 27-8-5.7
in effect

Ind. Code § 27-8-5.7-0.5 Applicability

Sec. 0.5. Sections 6.7 and 11.5 of this chapter, as added in the 2026 session of the general assembly, and section 10 of this chapter, as amended in the 2026 session of the general assembly, apply to claims submitted under an accident and sickness insurance policy that: (1) is issued, delivered, amended, or renewed after June 30, 2026; and (2) provides coverage during a plan year beginning after December 31, 2026. As added by P.L.88-2026, SEC.7.

Ind. Code § 27-8-5.7-1 "Accident and sickness insurance policy" defined

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

Ind. Code § 27-8-5.7-2 "Clean claim" defined

Sec. 2. As used in this chapter, "clean claim" means a claim submitted by a provider for payment under an accident and sickness insurance policy issued in Indiana that has no defect, impropriety, or particular circumstance requiring special treatment preventing payment. As added by P.L.162-2001, SEC.5.

Ind. Code § 27-8-5.7-2.5 "CPT code"

Sec. 2.5. As used in this chapter, "CPT code" refers to the medical billing code that applies to a specific health care service, as published in the Current Procedural Terminology code set maintained by the American Medical Association. As added by P.L.190-2023, SEC.26.

Ind. Code § 27-8-5.7-2.7 "Health provider facility"

Sec. 2.7. As used in this chapter, "health provider facility" has the meaning set forth in IC 27-1-37-3.2. As added by P.L.88-2026, SEC.8.

Ind. Code § 27-8-5.7-3 "Insurer" defined

Sec. 3. As used in this chapter, "insurer" means an insurance company issued a certificate of authority in Indiana to issue accident and 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 sickness insurance policy. As added by P.L.162-2001, SEC.5.

Ind. Code § 27-8-5.7-4 "Provider" defined

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

Ind. Code § 27-8-5.7-5 Notice of deficiencies in claims

Sec. 5. (a) An insurer shall pay or deny each clean claim in accordance with sections 6 and 6.5 of this chapter. (b) An insurer 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 an insurer 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.5. Amended by P.L.137-2002, SEC.2; P.L.190-2023, SEC.27.

Ind. Code § 27-8-5.7-6 Payment or denial of claims; interest

Sec. 6. (a) An insurer shall pay or deny each clean claim as follows: (1) If the claim is filed electronically, within thirty (30) days after the date the claim is received by the insurer. (2) If the claim is filed on paper, within forty-five (45) days after the date the claim is received by the insurer. (b) If: (1) an insurer fails to pay or deny a clean claim in the time required under subsection (a); and (2) the insurer subsequently pays the claim; the insurer shall pay the provider that submitted the claim interest on the accident and sickness insurance policy allowable amount of the claim 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), an insurer shall use the same interest rate as provided in IC 12-15-21-3(7)(A). As added by P.L.162-2001, SEC.5.

Ind. Code § 27-8-5.7-6.5 Prohibition on altering CPT code for claim; exceptions

Sec. 6.5. (a) An insurer may not alter the CPT code submitted for a clean claim or pay for a CPT code of lesser monetary value unless: (1) the CPT code submitted is not in accordance with correct coding guidelines and rules, clinical care guidelines, or the terms and conditions of the participating provider's agreement or contract with the insurer; or (2) the medical record of the clean claim has been reviewed by an employee or contractor of the insurer. (b) An insurer may not alter a clean claim to only pay for the CPT codes necessary for an individual's final diagnosis, if the CPT codes billed were deemed medically necessary according to generally accepted clinical care guidelines to reach the final diagnosis. (c) This section does not prohibit a provider from appealing a claim. As added by P.L.190-2023, SEC.28.

Ind. Code § 27-8-5.7-6.7 Prohibition on retroactive rate reduction; notice requirement

Sec. 6.7. (a) An insurer may not retroactively reduce the reimbursement rate for any CPT code. (b) An insurer shall provide at least sixty (60) days written notice by: (1) mail or electronic mail to a provider; and (2) posting on the insurer's website; before prospectively implementing a rate reduction for any CPT code. As added by P.L.88-2026, SEC.9.

Ind. Code § 27-8-5.7-7 Permitted forms

Sec. 7. A provider shall submit only the following forms for payment by an insurer: (1) CMS-1500. (2) CMS-1450 (UB-04). (3) American Dental Association (ADA) claim form. As added by P.L.162-2001, SEC.5. Amended by P.L.208-2018, SEC.10.

Ind. Code § 27-8-5.7-8 Civil penalties

Sec. 8. (a) If the commissioner finds that an insurer 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 insurer according to the following schedule: (1) If the insurer 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 insurer 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 insurer 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 insurer's failure to achieve the standards established by this chapter is due to circumstances beyond the insurer's control. (c) An insurer 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 insurer 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 insurer 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.5.

Ind. Code § 27-8-5.7-10 Limitations on recouping, auditing, and correcting payment errors

Sec. 10. (a) An insurer may not, more than one hundred eighty (180) days after the date on which an overpayment on a provider claim was made to the provider by the insurer: (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) An insurer may not recoup a paid claim more than one hundred eighty (180) days after the date on which the claim was initially paid. (c) An insurer may not retroactively audit a paid claim more than three (3) years after the date on which the claim was initially paid. (d) An insurer may not be required to correct a payment error to a provider if notice of the payment error is not provided within one hundred eighty (180) days after payment for a fully adjudicated claim is received. (e) Subsections (a), (b), and (d) do not apply in cases of fraud by the provider, the insured, or the insurer with respect to the health benefits claim on which the overpayment or underpayment was made when a final determination of fraud has been made by a court. (f) Notwithstanding subsections (a) through (d), an insurer and a hospital licensed under IC 16-21 may enter into a separate written agreement that provides for different time frames than those specified in this section. As added by P.L.55-2006, SEC.1. Amended by P.L.88-2026, SEC.10.

Ind. Code § 27-8-5.7-11 Claim overpayment adjustment

Sec. 11. Every subsequent claim that is adjusted by an insurer 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 overpaid amount; and (2) the amount of the overpayment that is being reimbursed to the insurer through the adjusted subsequent claim. As added by P.L.55-2006, SEC.2.

Ind. Code § 27-8-5.7-11.5 Error in coordination of benefits; submission of claim to appropriate insurer

Sec. 11.5. (a) If an insurer or a health maintenance organization (as defined in IC 27-13-36.2-2) recoups payment from a provider due to an error in coordination of benefits, the provider may submit a claim for the same services to the appropriate insurer. (b) Except as provided in subsection (d) and notwithstanding any other provision of law, a provider may submit a claim to the appropriate insurer not later than ninety (90) days after the date the recoupment is made. (c) A provider that submits a claim under this section shall provide documentation to the insurer demonstrating: (1) the original submission of the claim to the initial insurer or health maintenance organization; and (2) the recoupment of payment by the initial insurer or health maintenance organization due to an error in coordination of benefits. (d) Nothing in this section prevents an insurer from allowing a provider more time to submit a claim. As added by P.L.88-2026, SEC.11.

Ind. Code § 27-8-5.7-12 Prohibition on denial of claim based on out of network provider referral

Sec. 12. (a) This section applies to a policy of accident and sickness insurance that is issued, delivered, amended, or renewed after June 30, 2025. (b) An insurer may not deny a claim for reimbursement for a covered service or item provided to an insured on the sole basis that the referring provider is an out of network provider. As added by P.L.144-2025, SEC.37 and P.L.215-2025, SEC.63.
Source: Open US Law by Vaquill AI (CC BY 4.0)URL: https://iga.in.gov/laws/2026/ic/titles/27Fetched: 10/17/2026