Sec. 13. (a) This section applies to a claim filed after December 31, 2018, for a medically necessary health care service rendered by a participating provider, the necessity of which:

(1) is not anticipated at the time prior authorization is obtained for another health care service; and

Terms Used In Indiana Code 27-1-37.5-13

  • Contract: A legal written agreement that becomes binding when signed.
  • health care service: means a health care related service or product rendered or sold by a health care provider within the scope of the health care provider's license or legal authorization, including hospital, medical, surgical, mental health, and substance abuse services or products. See Indiana Code 27-1-37.5-4
  • health plan: means any of the following that provides coverage for health care services:

    Indiana Code 27-1-37.5-5

  • participating provider: refers to the following:

    Indiana Code 27-1-37.5-6

  • prior authorization: means a practice implemented by a health plan through which coverage of a health care service is dependent on the covered individual or health care provider obtaining approval from the health plan before the health care service is rendered. See Indiana Code 27-1-37.5-7
(2) is determined at the time the other health care service is rendered.

     (b) The health plan shall not deny a claim described in subsection (a) based solely on lack of prior authorization for the unanticipated health care service.

     (c) The health plan:

(1) shall not deny payment for a health care service that is rendered in accordance with:

(A) a prior authorization; and

(B) all terms and conditions of the participating provider’s agreement or contract with the health plan; and

(2) may:

(A) require retrospective review of; and

(B) withhold payment for;

an unanticipated health care service described in subsection (a).

As added by P.L.77-2018, SEC.2.

  Previous section
Next section  
 Chapter 37.5 Contents