§ 27-13-37-2 — Use of participating provider other than primary care provider

Indiana § 27-13-37-2

• Jurisdiction: Indiana
• Title 27: INSURANCE
• Art. 13: HEALTH MAINTENANCE ORGANIZATIONS
• Ch. 37: Patient Protection; Choice of Health Care Professional

Text

(a) Each health maintenance organization
shall develop a system to allow an enrollee to use an appropriate
participating provider to manage the enrollee's medical condition when
the enrollee's primary care provider determines that the use of another
appropriate participating provider is warranted by the enrollee's
medical condition.
(b) A primary care provider who makes the required determination
under subsection (a) shall refer the enrollee to a participating provider
whom the primary care provider determines is appropriate.
(c) A health maintenance organization shall provide coverage under
this section for treatment received by an enrollee from an appropriate
participating provider when the enrollee is referred to the participating
provider as provided in this section for as long as the treatment is
appropriate for the medical condition, subject to the terms and
conditions of the enrollee's contract with the health maintenance
organization.
(d) A contract between a health maintenance organization and a
primary care provider may not provide for a financial or other penalty
to the primary care provider for making a referral allowed under this
section.

Legislative History

As added by P.L.69-1998, SEC.15.