§ 27-1-37.5-12 — Claim for which prior authorization was given; denial; resubmission of claim

Indiana § 27-1-37.5-12

• Jurisdiction: Indiana
• Title 27: INSURANCE
• Art. 1: DEPARTMENT OF INSURANCE
• Ch. 37.5: Health Care Service Prior Authorization

Text

(a) This section applies to a claim for a
health care service rendered by a health care provider:
(1) for which:
(A) prior authorization is requested after June 30, 2025; and
(B) a utilization review entity gives prior authorization; and
(2) that is rendered in accordance with the authorization.
(b) The utilization review entity shall not deny the claim described
in subsection (a) unless:
(1) the health care provider knowingly and materially
misrepresented the health care service in the prior authorization
request with the specific intent to deceive and obtain an unlawful
payment from the utilization review entity;
(2) the health care service was no longer a covered benefit on the
date the health care service was provided;
(3) the health care provider was no longer contracted with the
patient's health plan on the date the health care service was
provided;
(4) the health care provider failed to meet the utilization review
entity's timely filing requirements;
(5) the utilization review entity does not have liability for the
claim; or
(6) the patient was not covered under the health plan on the date
on which the health care service was rendered.
(c) If:
(1) the claim described in subsection (a) contains an unintentional
and inaccurate inconsistency with the request for prior
authorization; and
(2) the inconsistency results in denial of the claim;
the health care provider may resubmit the claim with accurate,
corrected information.

Legislative History

As added by P.L.77-2018, SEC.2. Amended by P.L.144-2025, SEC.21.