§ 27-13-43-4 — Fully credentialed provider reimbursement; requirements

Indiana § 27-13-43-4

• Jurisdiction: Indiana
• Title 27: INSURANCE
• Art. 13: HEALTH MAINTENANCE ORGANIZATIONS
• Ch. 43: Credentialing

Text

(a) A fully credentialed provider shall be
reimbursed for eligible services provided at any in-network hospital if
the following conditions are met:
(1) The provider submits the documentation required by the
health maintenance organization to be loaded under the provider
group or hospital.
(2) The provider, provider group, or hospital is a network provider
with the health maintenance organization.
(3) The services are provided in accordance with all terms and
conditions of the provider's, group provider's, or hospital's
agreement or contract with the health maintenance organization.
(4) Prior authorization is obtained in accordance with IC 27-1-37.5 when required by the health maintenance organization
for an eligible service.
(b) The health maintenance organization shall reimburse the
provider or hospital for services described in subsection (a) at the rates
determined by the contract between the provider and the health
maintenance organization.
(c) A health maintenance organization is not required to credential
a provider. However, if:
(1) a provider is employed by a hospital that is part of the
hospital's network that is covered by the health maintenance
organization; and
(2) the provider meets the health maintenance organization's
credentialing requirements;
the health maintenance organization shall reimburse the provider for
any reimbursable services from the date that the provider was
employed by the hospital.

Legislative History

As added by P.L.50-2020, SEC.9.