Insurance Companies Disputes

This section applies specifically to insurance companies which are regulated by Indiana. Plans which are self-insured or subject to ERISA are not governed by Indiana law. Contact the Indiana Department of Insurance if you are unsure about a particular company.

Prompt Payment of Claims

  1. Accident and sickness insurance companies and HMOs must notify physicians of any deficiencies in submitted claims within 30 days if they are electronic claims and 45 days if they are paper claims. IC 27-13-36.2-3 (HMO); IC 27-8-5.7-5 (accident and sickness insurance company)
  2. If the claims are “clean,” they must be paid within 30 days for electronic claims and 45 days for paper claims. IC 27-13-36.2-4 (HMO); IC 27-8-5.7-6 (accident and sickness insurance company)
  3. Claims which are not timely paid are subject to interest. IC 27-13-36.2-4 (HMO); IC 27-8-5.7-6 (accident and sickness insurance company). The rate for 2006 was 2%. The rate for 2007 has not yet been posted – see updates.
  4. “Clean claim” – A “clean claim” is defined as a claim submitted by a provider for payment under an accident and sickness insurance policy issued in Indiana or to an HMO that has no defect, impropriety, or particular circumstance requiring special treatment preventing payment. IC 27-13-36.2-1 (HMO) and IC 27-8-5.7-2 (accident and sickness insurance company)

Requests for Refunds (Take Back Law)

  1. Insurance companies must request any refunds of overpayments to physicians within two (2) years of the date of the overpayment (not the date of service). IC 27-13-36.2-8 (HMO); IC 27-8-5.7-10 (accident and sickness insurance company)
  2. The request must include an explanation of the reason for the adjustment, including:
    • an identification of:
      • (A) the claim on which the overpayment was made; and
      • (B) if ascertainable, the party financially responsible for the overpaid amount; and
    • the amount of the overpayment that is being reimbursed to the insurer through the adjusted subsequent claim. IC 27-13-36.2-9 (HMO); IC 27-8-5.7-11 (accident and sickness insurance company)
  3. Anthem/Wellpoint is restricted to 18 months (not two years) under the terms of a national class action settlement.

Disputes with Insurance Companies

  1. Check your contract (where applicable) and follow the grievance and appeal procedures. (Note that some contracts may require that you “exhaust” your administrative grievance and appeal options before you can take other steps, such as filing a lawsuit.)
  2. File a complaint with the Indiana Department of Insurance.
  3. File a HMO class action lawsuit compliance dispute (for violation of the terms of a national class action settlement).

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