Promulgation of forms; requisites; contents; acceptance of claims; explanation of benefits paid statements or claims summary statements
Sec. 2. (a) The commissioner shall prescribe by rule, after consultation with providers of health care or treatment, accident and sickness insurers, hospital, medical, and dental service corporations and other prepayment organizations, such accident and sickness insurance claim forms as the commissioner determines will provide for uniformity and simplicity in insurance reporting. The forms shall include, but need not be limited to, information regarding the medical diagnosis, treatment and prognosis of the patient, together with the details of charges incident to the providing of care, treatment or services, sufficient for the purpose of meeting the proof requirements of an accident or sickness insurance policy or a hospital, medical, or dental service contract.
(b) An accident and sickness insurer may not refuse to accept a claim submitted on duly promulgated uniform claim forms. However, an insurer may accept claims submitted on any other form.
(c) Accident and sickness insurer explanation of benefits paid statements or claims summary statements sent to an insured by the accident and sickness insurer may be sent in electronic or paper form and shall be in a format and written in a manner that promotes understanding by the insured by setting forth:
(1) the total dollar amount submitted to the insurer for payment;
(2) any reduction in the amount paid due to the application of any co-payment or deductible, along with an explanation of the amount of the co-payment or deductible applied under the insured's policy;
(3) any reduction in the amount paid due to the application of any other policy limitation or exclusion as set forth in the insured's policy along with an explanation thereof;
(4) the total dollar amount paid; and
(5) the total dollar amount remaining unpaid.
In addition, the explanation shall clearly set forth a toll free number that the insured may call to obtain additional information about any of the items contained in the explanation of benefits paid or claims
(d) The commissioner may issue an order under IC 27-1-3-19(a) directing an accident and sickness insurer to comply with subsection (c).
(e) An accident and sickness insurer does not violate subsection (c) by using a document that the accident and sickness insurer has been required to use by the federal government or the state.
(f) An accident and sickness insurer shall:
(1) inform an insured that the insured may request that the statements described in subsection (c) be sent in paper form; and
(2) send the statements in paper form upon the request of the insured.
As added by Acts 1977, P.L.288, SEC.1. Amended by P.L.252-1989, SEC.1; P.L.125-2005, SEC.4.
Obtaining additional information regarding claims
Sec. 3. The adoption of uniform claim forms by the commissioner pursuant to this chapter does not preclude an insurer, hospital, medical, or dental service corporation or other pre-payment organization, from obtaining any necessary additional information regarding a claim from the claimant, provider of health care or treatment, or certifier of coverage, as may be required.
As added by Acts 1977, P.L.288, SEC.1.