Sec. 5. (a) A
claim review agent may not conduct
medical claims review concerning health care services delivered to an
enrollee in Indiana unless the claim review agent holds a certificate of registration issued by the
department under this chapter.
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Terms Used In Indiana Code 27-8-16-5
- claim review agent: means any entity performing medical claims review on behalf of an insurance company, a health maintenance organization, or another benefit program providing payment, reimbursement, or indemnification for health care costs to an enrollee. See Indiana Code 27-8-16-1
- department: refers to the department of insurance. See Indiana Code 27-8-16-2
- enrollee: means an individual who has contracted for or who participates in coverage under an insurance policy, a health maintenance organization contract, or another benefit program providing payment, reimbursement, or indemnification for the costs of health care for:
Indiana Code 27-8-16-3
- medical claims review: means the determination of the reimbursement to be provided under the terms of an insurance policy, a health maintenance organization contract, or another benefit program providing payment, reimbursement, or indemnification for health care costs based on the appropriateness of health care services or the amount charged for a health care service delivered to an enrollee. See Indiana Code 27-8-16-4
- person: means an individual, a corporation, a limited liability company, a partnership, or an unincorporated association. See Indiana Code 27-8-16-4.5
- Verified: when applied to pleadings, means supported by oath or affirmation in writing. See Indiana Code 1-1-4-5
(1) The name, address, telephone number, and normal business hours of the claim review agent.
(2) The name and telephone number of a person that the department may contact concerning the information in the application.
(3) Documentation necessary for the department to determine that the claim review agent is capable of satisfying the minimum requirements set forth in section 7 of this chapter.
(c) An application submitted under this section must be:
(1) signed and verified by the applicant; and
(2) accompanied by an application fee in the amount established under subsection (d).
The commissioner shall deposit an application fee collected under this subsection into the department of insurance fund established by IC 27-1-3-28.
(d) The department shall set the amount of the application fee required by subsection (c) and section 6(a) of this chapter in the rules adopted under section 14 of this chapter. The amount may not be more than is reasonably necessary to generate revenue sufficient to offset the costs incurred by the department in carrying out the department’s responsibilities under this chapter.
(e) The department shall issue a certificate of registration to a claim review agent that satisfies the requirements of this section.
As added by P.L.128-1992, SEC.2. Amended by P.L.260-1995, SEC.4; P.L.173-2007, SEC.36; P.L.234-2007, SEC.193.
