Indiana Code 27-1-37.5-12. Claim for which prior authorization was given; denial; resubmission of claim
(1) for which:
Terms Used In Indiana Code 27-1-37.5-12
- Contract: A legal written agreement that becomes binding when signed.
- covered individual: means an individual who is covered under a health plan. See Indiana Code 27-1-37.5-2
- 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
(B) a health plan gives prior authorization; and
(2) that is rendered in accordance with:
(A) the prior authorization; and
(B) all terms and conditions of the participating provider’s agreement or contract with the health plan.
(b) The health plan shall not deny the claim described in subsection (a) unless:
(1) the:
(A) request for prior authorization; or
(B) claim;
contains fraudulent or materially incorrect information; or
(2) the covered individual is not covered under the health plan on the date on which the health care service is rendered.
(c) If:
(1) the claim described in subsection (a) contains an unintentional and inaccurate inconsistency with the request for prior authorization; and
(2) the inconsistency results in denial of the claim;
the health care provider may resubmit the claim with accurate, corrected information.
As added by P.L.77-2018, SEC.2.