§ 27-8-5.5-2 — Promulgation of forms; requisites; contents; acceptance of claims; explanation of benefits paid statements or claims summary statements

Indiana § 27-8-5.5-2

• Jurisdiction: Indiana
• Title 27: INSURANCE
• Art. 8: LIFE, ACCIDENT, AND HEALTH
• Ch. 5.5: Accident and Sickness Insurance─Claim Forms

Text

(a) The commissioner shall prescribe by rule,
after consultation with providers of health care or treatment, accident
and sickness insurers, hospital, medical, and dental service
corporations and other prepayment organizations, such accident and
sickness insurance claim forms as the commissioner determines will
provide for uniformity and simplicity in insurance reporting. The forms
shall include, but need not be limited to, information regarding the
medical diagnosis, treatment and prognosis of the patient, together with
the details of charges incident to the providing of care, treatment or
services, sufficient for the purpose of meeting the proof requirements
of an accident or sickness insurance policy or a hospital, medical, or
dental service contract.
(b) An accident and sickness insurer may not refuse to accept a
claim submitted on duly promulgated uniform claim forms. However,
an insurer may accept claims submitted on any other form.
(c) Accident and sickness insurer explanation of benefits paid
statements or claims summary statements sent to an insured by the
accident and sickness insurer may be sent in electronic or paper form
and shall be in a format and written in a manner that promotes
understanding by the insured by setting forth:
(1) the total dollar amount submitted to the insurer for payment;
(2) any reduction in the amount paid due to the application of any
co-payment or deductible, along with an explanation of the
amount of the co-payment or deductible applied under the
insured's policy;
(3) any reduction in the amount paid due to the application of any
other policy limitation or exclusion as set forth in the insured's
policy along with an explanation thereof;
(4) the total dollar amount paid; and
(5) the total dollar amount remaining unpaid.
In addition, the explanation shall clearly set forth a toll free number
that the insured may call to obtain additional information about any of
the items contained in the explanation of benefits paid or claims
summary statement.
(d) The commissioner may issue an order under IC 27-1-3-19(a)
directing an accident and sickness insurer to comply with subsection
(c).
(e) An accident and sickness insurer does not violate subsection (c)
by using a document that the accident and sickness insurer has been
required to use by the federal government or the state.
(f) An accident and sickness insurer shall:
(1) inform an insured that the insured may request that the
statements described in subsection (c) be sent in paper form; and
(2) send the statements in paper form upon the request of the
insured.
As added by Acts 1977, P.L.288, SEC.1. Amended by
P.L.252-1989, SEC.1; P.L.125-2005, SEC.4.