Indiana § 27-8-11-7 Applicability; credentialing; application; notification; response; status
notification; provisional credential; retroactive reimbursement;
termination

Indiana Statutes

§ 27-8-11-7 — Applicability; credentialing; application; notification; response; status notification; provisional credential; retroactive reimbursement; termination

Indiana § 27-8-11-7

Title 27INSURANCE

Art. 8LIFE, ACCIDENT, AND HEALTH

Ch. 11Accident and Sickness Insurance─Reimbursement

This text of Indiana § 27-8-11-7 (Applicability; credentialing; application; notification; response; status notification; provisional credential; retroactive reimbursement; termination) is published on Counsel Stack Legal Research, covering Indiana primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook

Ind. Code § 27-8-11-7 (2026).

Text

(a)This section applies to an insurer that issues or administers a policy that provides coverage for basic health care services (as defined in IC 27-13-1-4).

(b)As used in this section, "clean credentialing application" means an application for network participation that:

(1)is submitted by a provider under this section;

(2)does not contain an error; and

(3)may be processed by the insurer without returning the application to the provider for a revision or clarification.

(c)As used in this section, "credentialing" means a process by which an insurer makes a determination that:

(1)is based on criteria established by the insurer; and

(2)concerns whether a provider is eligible to:

(A)provide health services to an individual eligible for coverage; and

(B)receive reimbursement for the

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(a) This section applies to an insurer that issues
or administers a policy that provides coverage for basic health care
services (as defined in IC 27-13-1-4).
(b) As used in this section, "clean credentialing application" means
an application for network participation that:
(1) is submitted by a provider under this section;
(2) does not contain an error; and
(3) may be processed by the insurer without returning the
application to the provider for a revision or clarification.
(c) As used in this section, "credentialing" means a process by
which an insurer makes a determination that:
(1) is based on criteria established by the insurer; and
(2) concerns whether a provider is eligible to:
(A) provide health services to an individual eligible for
coverage; and
(B) receive reimbursement for the health services;
under an agreement that is entered into between the provider and
the insurer.
(d) As used in this section, "unclean credentialing application"
means an application for network participation that:
(1) is submitted by a provider under this section;
(2) contains at least one (1) error; and
(3) must be returned to the provider to correct the error.
(e) The department of insurance shall prescribe the credentialing
application form used by the Council for Affordable Quality Healthcare
(CAQH) in electronic or paper format, which must be used by:
(1) a provider who applies for credentialing by an insurer; and
(2) an insurer that performs credentialing activities.
(f) An insurer shall notify a provider concerning a deficiency on a
completed unclean credentialing application form submitted by the
provider not later than five (5) business days after the entity receives
the completed unclean credentialing application form. A notice
described in this subsection must:
(1) provide a description of the deficiency; and
(2) state the reason why the application was determined to be an
unclean credentialing application.
(g) A provider shall respond to the notification required under
subsection (f) not later than five (5) business days after receipt of the
notice.
(h) An insurer shall notify a provider concerning the status of the
provider's completed clean credentialing application when:
(1) the provider is provisionally credentialed; and
(2) the insurer makes a final credentialing determination
concerning the provider.
(i) If the insurer fails to issue a credentialing determination within
fifteen (15) business days after receiving a completed clean
credentialing application form from a provider, the insurer shall
provisionally credential the provider in accordance with the standards
and guidelines governing provisional credentialing from the National
Committee for Quality Assurance or its successor organization. The
provisional credentialing license is valid until a determination is made
on the credentialing application of the provider.
(j) Once an insurer fully credentials a provider that holds
provisional credentialing and a network provider agreement has been
executed, then reimbursement payments under the contract shall be
paid retroactive to the date the provider was provisionally credentialed.
The insurer shall reimburse the provider at the rates determined by the
contract between the provider and the insurer.
(k) If an insurer does not fully credential a provider that is
provisionally credentialed under subsection (i), the provisional
credentialing is terminated on the date the insurer notifies the provider
of the adverse credentialing determination. The insurer is not required
to reimburse for services rendered while the provider was provisionally
credentialed.