Indiana Code 27-13-36.2-4.5. Prohibition on altering CPT code for claim; exceptions
Current as of: 2023 | Check for updates
|
Other versions
Sec. 4.5. (a) A health maintenance organization may not alter the CPT code (as defined in IC 27-1-37.5-3) submitted for a clean claim or pay for a CPT code (as defined in IC 27-1-37.5-3) of lesser monetary value unless:
(2) the medical record of the clean claim has been reviewed by an employee or contractor of the health maintenance organization.
(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 health maintenance organization; or
Terms Used In Indiana Code 27-13-36.2-4.5
- clean claim: means a claim submitted by a provider for payment for health care services provided to an enrollee that has no defect, impropriety, or particular circumstance requiring special treatment preventing payment. See Indiana Code 27-13-36.2-1
- Contract: A legal written agreement that becomes binding when signed.
- health maintenance organization: includes :
Indiana Code 27-13-36.2-2
- medical record: means written or printed information possessed by a provider (as defined in Ind. See Indiana Code 1-1-4-5
(b) A health maintenance organization may not alter a clean claim to only pay for the CPT codes (as defined in IC 27-1-37.5-3) necessary for an individual’s final diagnosis, if the CPT codes (as defined in IC 27-1-37.5-3) 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.
As added by P.L.190-2023, SEC.35.