§ 27-13-36.2-4.5 — Prohibition on altering CPT code for claim; exceptions

Indiana § 27-13-36.2-4.5

• Jurisdiction: Indiana
• Title 27: INSURANCE
• Art. 13: HEALTH MAINTENANCE ORGANIZATIONS
• Ch. 36.2: Provider Payment

Text

5. (a) A health maintenance organization
may not alter the CPT code (as defined in IC 27-1-37.5-3) submitted
for a clean claim or pay for a CPT code (as defined in IC 27-1-37.5-3)
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 health maintenance organization; or
(2) the medical record of the clean claim has been reviewed by an
employee or contractor of the health maintenance organization.
(b) A health maintenance organization may not alter a clean claim
to only pay for the CPT codes (as defined in IC 27-1-37.5-3) necessary
for an individual's final diagnosis, if the CPT codes (as defined in IC 27-1-37.5-3) 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.

Legislative History

As added by P.L.190-2023, SEC.35.