§ 27-8-11-14 — Definitions; assignment of benefits; direct payment to provider; payment in full

Indiana § 27-8-11-14

• Jurisdiction: Indiana
• Title 27: INSURANCE
• Art. 8: LIFE, ACCIDENT, AND HEALTH
• Ch. 11: Accident and Sickness Insurance─Reimbursement

Text

(a) As used in this section, "covered
individual" means an individual who is entitled to the coverage of
dental services by a dental carrier.
(b) As used in this section, "dental carrier" means any of the
following:
(1) An insurer that issues a policy of accident and sickness
insurance that covers dental services.
(2) A health maintenance organization that provides, or provides
coverage for, dental services.
(3) A preferred provider plan subject to this chapter under which
dental services are provided.
(c) As used in this section, "dental services" means health care
services provided by:
(1) a dentist licensed under IC 25-14;
(2) an individual using a dental residency permit issued under IC 25-14-1-5;
(3) an individual who holds:
(A) a dental faculty license under IC 25-14-1-5.5; or
(B) an instructor's license under IC 25-14-1-27.5;
(4) a dental hygienist licensed under IC 25-13; or
(5) a dental assistant (as defined in IC 25-14-1-1.5(4));
within the scope of the individual's license or work description in IC 25-13 or IC 25-14, as appropriate. However, the term does not include
a service delivered by a provider if the service is billed as a medical
expense.
(d) As used in this section, "network" means all providers that have
entered into a contract with a dental carrier under which the providers
agree to charge no more than a certain amount for certain dental
services provided to covered individuals who are entitled to the
coverage of dental services by the dental carrier.
(e) As used in this section, "provider" means:
(1) a dentist licensed under IC 25-14; or
(2) a dental office through which one (1) or more dentists licensed
under IC 25-14 provide dental services.
(f) If a covered individual assigns the rights of the covered
individual to benefits for dental services to the provider of the dental
services, the covered individual's dental carrier shall pay the benefits
assigned by the covered individual to the provider of the dental
services.
(g) A dental carrier shall make a payment under this section:
(1) directly to the provider of the dental services; and
(2) according to the same criteria and payment schedule under
which the dental carrier would have been required to make the
payment to the covered individual if the insured had not assigned
the insured's rights to the benefits.
(h) An assignment of benefits under this section does not affect or
limit the dental carrier's obligation to pay the benefits.
(i) A dental carrier's payment of benefits in compliance with this
section discharges the dental carrier's obligation to pay the benefits to
the insured.
(j) If:
(1) a covered individual is entitled to coverage from a dental
carrier;
(2) the covered individual is provided dental services by a
provider;
(3) the covered individual assigns the covered individual's rights
to benefits from the dental carrier to the provider of the dental
services; and
(4) the provider of the dental services is a member of the network
of the dental carrier;
the provider shall accept compensation from the dental carrier in the
amount specified in the network contract as payment in full for the
dental services provided to the covered individual and shall not bill the
covered individual for the dental services, except for copayments,
coinsurance and any deductible amount that remains after the dental
carrier's payment for the dental services.

Legislative History

As added by P.L.17-2024, SEC.21.