Sec. 12. (a) This section does not apply to a referral made by a provider that has confirmed that the provider to which a covered individual is referred is a network provider with respect to the covered individual’s health plan.

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Terms Used In Indiana Code 25-1-9.1-12

  • covered individual: means an individual who is entitled to coverage under a health plan. See Indiana Code 25-1-9.1-3
  • health plan: means :

    Indiana Code 25-1-9.1-5

  • network: means a group of two (2) or more providers that have entered into:

    Indiana Code 25-1-9.1-6

  • network provider: means a provider described in section 6 of this chapter. See Indiana Code 25-1-9.1-7
  • out of network provider: means a provider that is not described in section 6 of this chapter. See Indiana Code 25-1-9.1-8
  • provider: means a practitioner described in IC 25-1-9-2(a)(1). See Indiana Code 25-1-9.1-9
  • referral: means a recommendation or direction made by a provider to a covered individual that the covered individual receive a health care item or service rendered by another provider that is not affiliated with the first provider. See Indiana Code 25-1-9.1-11
     (b) A provider that makes a referral shall provide to the covered individual an electronic or paper copy of written notice that states all of the following:

(1) That an out of network provider may be called upon to render health care items or services to the covered individual during the course of treatment.

(2) That an out of network provider described in subdivision (1) is not bound by the payment provisions that apply to health care items or services rendered by a network provider under the covered individual’s health plan.

(3) That the covered individual may contact the covered individual’s health plan before receiving health care items or services rendered by an out of network provider described in subdivision (1):

(A) to obtain a list of network providers that may render the health care items or services; and

(B) for additional assistance.

     (c) A provider that makes a referral via telephone to a patient of record shall provide to the covered individual all of the following information:

(1) That an out of network provider may be called upon to render health care items or services to the covered individual during the course of treatment.

(2) That an out of network provider described in subdivision (1) is not bound by the payment provisions that apply to health care items or services rendered by a network provider under the covered individual’s health plan.

(3) That the covered individual may contact the covered individual’s health plan before receiving health care items or services rendered by an out of network provider described in subdivision (1):

(A) to obtain a list of network providers that may render the health care items or services; and

(B) for additional assistance.

(4) The provider shall note in the covered individual’s medical chart:

(A) the name of the provider to whom the covered individual was referred; and

(B) that the referral was made via telephone.

As added by P.L.147-2017, SEC.1. Amended by P.L.121-2018, SEC.2; P.L.182-2018, SEC.2.

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