Indiana Code 27-8-5.7-6.5. Prohibition on altering CPT code for claim; exceptions
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Sec. 6.5. (a) An insurer may not alter the CPT code submitted for a clean claim or pay for a CPT code of lesser monetary value unless:
(2) the medical record of the clean claim has been reviewed by an employee or contractor of the insurer.
(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 insurer; or
Terms Used In Indiana Code 27-8-5.7-6.5
- clean claim: means a claim submitted by a provider for payment under an accident and sickness insurance policy issued in Indiana that has no defect, impropriety, or particular circumstance requiring special treatment preventing payment. See Indiana Code 27-8-5.7-2
- Contract: A legal written agreement that becomes binding when signed.
- CPT code: refers to the medical billing code that applies to a specific health care service, as published in the Current Procedural Terminology code set maintained by the American Medical Association. See Indiana Code 27-8-5.7-2.5
- insurer: means an insurance company issued a certificate of authority in Indiana to issue accident and sickness insurance policies. See Indiana Code 27-8-5.7-3
- medical record: means written or printed information possessed by a provider (as defined in IC 16-18-2-295) concerning any diagnosis, treatment, or prognosis of the patient, unless otherwise defined. See Indiana Code 1-1-4-5
- provider: has the meaning set forth in IC 27-8-11-1. See Indiana Code 27-8-5.7-4
(b) An insurer may not alter a clean claim to only pay for the CPT codes necessary for an individual’s final diagnosis, if the CPT codes 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.28.