Indiana Code 27-13-36-12. Payment to enrollee for service rendered by nonparticipating provider; requirements
(1) A statement specifying the claims covered by the payment instrument.
(2) The name and address of the provider submitting each claim.
(3) The amount paid by the health maintenance organization for each claim.
(4) Any amount of a claim that is the enrollee’s responsibility.
(5) A statement in at least 24 point bold type that:
(A) instructs the enrollee to use the payment to pay the nonparticipating provider if the enrollee has not paid the nonparticipating provider in full;
(B) specifies that paying the nonparticipating provider is the enrollee’s responsibility; and
(C) states that the failure to make the payment violates the law and may result in collection proceedings or criminal penalties.
As added by P.L.144-2009, SEC.3.