Note: This version of section effective until 7-1-2025. See also
following version of this section, effective 7-1-2025.
Sec. 4.
(a)A plan sponsor that contracts with a third
party administrator, the office of the secretary of family and social
services that contracts with a managed care organization (as defined in
IC 12-7-2-126.9) to provide services to a Medicaid recipient, or the
state personnel department that contracts with a prepaid health care
delivery plan under IC 5-10-8-7(c) to provide group health coverage for
state employees may, one (1) time in a calendar year and not earlier
than six (6) months following a previously requested audit, request an
audit of compliance with the contract. If requested by the plan sponsor,
office of the secretary of family and social services, or st
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Note: This version of section effective until 7-1-2025. See also
following version of this section, effective 7-1-2025.
Sec. 4. (a) A plan sponsor that contracts with a third
party administrator, the office of the secretary of family and social
services that contracts with a managed care organization (as defined in
IC 12-7-2-126.9) to provide services to a Medicaid recipient, or the
state personnel department that contracts with a prepaid health care
delivery plan under IC 5-10-8-7(c) to provide group health coverage for
state employees may, one (1) time in a calendar year and not earlier
than six (6) months following a previously requested audit, request an
audit of compliance with the contract. If requested by the plan sponsor,
office of the secretary of family and social services, or state personnel
department, the audit shall include full disclosure of the following
concerning data specific to the plan sponsor, office of the secretary, or
state personnel department:
(1) Claims data described in section 1 of this chapter.
(2) Claims received by the third party administrator, managed
care organization, or prepaid health care delivery plan on any of
the following:
(A) The CMS-1500 form or its successor form.
(B) The HCFA-1500 form or its successor form.
(C) The HIPAA X12 837P electronic claims transaction for
professional services, or its successor transaction.
(D) The HIPAA X12 837I institutional form or its successor
form.
(E) The CMS-1450 form or its successor form.
(F) The UB-04 form or its successor form.
The forms or transaction may be modified as necessary to comply
with the federal Health Insurance Portability and Accountability
Act (HIPAA) (P.L. 104-191) or to redact a trade secret (as defined
in IC 24-2-3-2).
(3) Claims payments, electronic funds transfer, or remittance
advice notices provided by the third party administrator, managed
care organization, or prepaid health care delivery plan as ASC
X12N 835 files or a successor format. The files may be modified
only as necessary to comply with the federal Health Insurance
Portability and Accountability Act (HIPAA) (P.L. 104-191) or to
redact a trade secret (as defined in IC 24-2-3-2). In the event that
paper claims are provided, the third party administrator, managed
care organization, or prepaid health care delivery plan shall
convert the paper claims to the ASC X12N 835 electronic format
or a successor format.
(4) Any fees charged to the plan sponsor, office of the secretary
of family and social services, or state personnel department
related to plan administration and claims processing, including
renegotiation fees, access fees, repricing fees, or enhanced review
fees.
(b) A third party administrator, managed care organization, or
prepaid health care delivery plan may not impose:
(1) fees for:
(A) requesting an audit under this section; or
(B) selecting an auditor other than an auditor designated by the
third party administrator, managed care organization, or prepaid
health care delivery plan; or
(2) conditions that would restrict a party's right to conduct an
audit under this section, including restrictions on the:
(A) time period of the audit;
(B) number of claims analyzed;
(C) type of analysis conducted;
(D) data elements used in the analysis; or
(E) selection of an auditor as long as the auditor:
(i) does not have a conflict of interest;
(ii) meets a threshold for liability insurance specified in the
contract between the parties;
(iii) does not work on a contingent fee basis; and
(iv) does not have a history of breaching nondisclosure
agreements.
(c) A third party administrator, managed care organization, or
prepaid health care delivery plan shall provide claims data to the
contract holder not later than fifteen (15) business days after the claims
data is requested.
(d) Information provided in an audit under this section must be
provided in accordance with the federal Health Insurance Portability
and Accountability Act (HIPAA) (P.L. 104-191).
(e) A contract that is entered into, issued, amended, or renewed after
June 30, 2024, may not contain a provision that violates this section.
(f) A violation of this section is an unfair or deceptive act or practice
in the business of insurance under IC 27-4-1-4.
(g) The department may also adopt rules under IC 4-22-2 to set forth
fines for a violation under this section.