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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 varies each year. The rate for 2009 is 5%.
  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).

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.

Most Favored Nation Clauses (Reimbursement Rates)
Indiana law provides that an agreement between an insurer and a provider may not contain a provision that:

  1. Prohibits, or grants the insurer an option to prohibit, the provider from contracting with another insurer to accept lower payment for health care services than the payment specified in the agreement;
  2. Requires, or grants the insurer an option to require, the provider to accept a lower payment from the insurer if the provider agrees with another insurer to accept lower payment for health care services;
  3. Requires, or grants the insurer an option of, termination or renegotiation of the agreement if the provider agrees with another insurer to accept lower payment for health care services; or
  4. Requires the provider to disclose the provider’s reimbursement rates under contracts with other insurers.

A provision that is contained in an agreement between an insurer and a provider that violates any of the above is void.  IC 27-8-11-9.

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