§ 27-13-36-12 — Payment to enrollee for service rendered by nonparticipating provider; requirements

Indiana § 27-13-36-12

• Jurisdiction: Indiana
• Title 27: INSURANCE
• Art. 13: HEALTH MAINTENANCE ORGANIZATIONS
• Ch. 36: Patient Protection; Clinical Decision Making; Access

Text

(a) As used in this section,
"nonparticipating provider" means a provider that has not entered into
an agreement with a health maintenance organization to serve as a
participating provider.
(b) After September 30, 2009, if a health maintenance organization
makes a payment to an enrollee for a health care service rendered by a
nonparticipating provider, the health maintenance organization shall
include with the payment instrument written notice to the enrollee that
includes the following:
(1) A statement specifying the claims covered by the payment
instrument.
(2) The name and address of the provider submitting each claim.
(3) The amount paid by the health maintenance organization for
each claim.
(4) Any amount of a claim that is the enrollee's responsibility.
(5) A statement in at least 24 point bold type that:
(A) instructs the enrollee to use the payment to pay the
nonparticipating provider if the enrollee has not paid the
nonparticipating provider in full;
(B) specifies that paying the nonparticipating provider is the
enrollee's responsibility; and
(C) states that the failure to make the payment violates the law
and may result in collection proceedings or criminal penalties.

Legislative History

As added by P.L.144-2009, SEC.3.