Indiana § 27-8-5.7-6.5 Prohibition on altering CPT code for claim; exceptions

Indiana Statutes

§ 27-8-5.7-6.5 — Prohibition on altering CPT code for claim; exceptions

Indiana § 27-8-5.7-6.5

Title 27INSURANCE

Art. 8LIFE, ACCIDENT, AND HEALTH

Ch. 5.7Accident and Sickness Insurance; Provider Payment

This text of Indiana § 27-8-5.7-6.5 (Prohibition on altering CPT code for claim; exceptions) 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 § 27-8-5.7-6.5 (2026).

Text

5.

(a)An insurer may not alter the CPT code submitted for a clean claim or pay for a CPT code of lesser monetary value unless:

(1)the CPT code submitted is not in accordance with correct coding guidelines and rules, clinical care guidelines, or the terms and conditions of the participating provider's agreement or contract with the insurer; or

(2)the medical record of the clean claim has been reviewed by an employee or contractor of the insurer.

(b)An insurer may not alter a clean claim to only pay for the CPT codes necessary for an individual's final diagnosis, if the CPT codes billed were deemed medically necessary according to generally accepted clinical care guidelines to reach the final diagnosis.

(c)This section does not prohibit a provider from appealing a claim.

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5. (a) An insurer may not alter the CPT code
submitted for a clean claim or pay for a CPT code of lesser monetary
value unless:
(1) the CPT code submitted is not in accordance with correct
coding guidelines and rules, clinical care guidelines, or the terms
and conditions of the participating provider's agreement or
contract with the insurer; or
(2) the medical record of the clean claim has been reviewed by an
employee or contractor of the insurer.
(b) An insurer may not alter a clean claim to only pay for the CPT
codes necessary for an individual's final diagnosis, if the CPT codes
billed were deemed medically necessary according to generally
accepted clinical care guidelines to reach the final diagnosis.
(c) This section does not prohibit a provider from appealing a claim.