Ind. Code ch. 27-8-11

Ind. Code ch. 27-8-11
in effect

Ind. Code § 27-8-11-0.1 Application of certain amendments to chapter

Sec. 0.1. The addition of section 9 of this chapter by P.L.74-2007 applies to an agreement between an insurer and a provider that is entered into, amended, or renewed on or after April 26, 2007. As added by P.L.220-2011, SEC.441.

Ind. Code § 27-8-11-1 Definitions

Sec. 1. (a) The definitions in this section apply throughout this chapter. (b) "Credentialing" means a process through which an insurer makes a determination: (1) based on criteria established by the insurer; and (2) concerning whether a provider is eligible to: (A) provide health care services to an insured; and (B) receive reimbursement for the health care services; under an agreement entered into between the provider and the insurer under section 3 of this chapter. (c) "Health care services": (1) means health care related services or products rendered or sold by a provider within the scope of the provider's license or legal authorization; and (2) includes hospital, medical, surgical, dental, vision, and pharmaceutical services or products. (d) "Insured" means an individual entitled to reimbursement for expenses of health care services under a policy issued or administered by an insurer. (e) "Insurer" means an insurance company authorized in this state to issue policies that provide reimbursement for expenses of health care services. (f) "Person" means an individual, an agency, a political subdivision, a partnership, a corporation, an association, or any other entity. (g) "Preferred provider plan" means an undertaking to enter into agreements with providers relating to terms and conditions of reimbursements for the health care services of insureds, members, or enrollees relating to the amounts to be charged to insureds, members, or enrollees for health care services. (h) "Provider" means an individual or entity duly licensed or legally authorized to provide health care services. As added by P.L.140-1984, SEC.1. Amended by P.L.31-1988, SEC.22; P.L.26-2005, SEC.1.

Ind. Code § 27-8-11-2 Conflicting provisions

Sec. 2. To the extent of any conflict between this chapter and IC 27-4-1-4, IC 27-8-5-15, IC 27-8-6-1, or any other statutory provision, this chapter prevails over the conflicting provision. Agreements may be entered into under section 3(a)(1) of this chapter notwithstanding any contradictory policy provision prescribed under IC 27-8-5-3(a)(9). As added by P.L.140-1984, SEC.1. Amended by P.L.1-2010, SEC.111.

Ind. Code § 27-8-11-3 Reimbursement agreements; immunity

Sec. 3. (a) An insurer may: (1) enter into agreements with providers relating to terms and conditions of reimbursement for health care services that may be rendered to insureds of the insurer, including agreements relating to the amounts to be charged the insured for services rendered or the terms and conditions for activities intended to reduce inappropriate care; (2) issue or administer policies in this state that include incentives for the insured to utilize the services of a provider that has entered into an agreement with the insurer under subdivision (1); and (3) issue or administer policies in this state that provide for reimbursement for expenses of health care services only if the services have been rendered by a provider that has entered into an agreement with the insurer under subdivision (1). (b) Before entering into any agreement under subsection (a)(1), an insurer shall establish terms and conditions that must be met by providers wishing to enter into an agreement with the insurer under subsection (a)(1). These terms and conditions may not discriminate unreasonably against or among providers. For the purposes of this subsection, neither differences in prices among hospitals or other institutional providers produced by a process of individual negotiation nor price differences among other providers in different geographical areas or different specialties constitutes unreasonable discrimination. Upon request by a provider seeking to enter into an agreement with an insurer under subsection (a)(1), the insurer shall make available to the provider a written statement of the terms and conditions that must be met by providers wishing to enter into an agreement with the insurer under subsection (a)(1). (c) No hospital, physician, pharmacist, or other provider designated in IC 27-8-6-1 willing to meet the terms and conditions of agreements described in this section may be denied the right to enter into an agreement under subsection (a)(1). When an insurer denies a provider the right to enter into an agreement with the insurer under subsection (a)(1) on the grounds that the provider does not satisfy the terms and conditions established by the insurer for providers entering into agreements with the insurer, the insurer shall provide the provider with a written notice that: (1) explains the basis of the insurer's denial; and (2) states the specific terms and conditions that the provider, in the opinion of the insurer, does not satisfy. (d) In no event may an insurer deny or limit reimbursement to an insured under this chapter on the grounds that the insured was not referred to the provider by a person acting on behalf of or under an agreement with the insurer. (e) No cause of action shall arise against any person or insurer for: (1) disclosing information as required by this section; or (2) the subsequent use of the information by unauthorized individuals. Nor shall such a cause of action arise against any person or provider for furnishing personal or privileged information to an insurer. However, this subsection provides no immunity for disclosing or furnishing false information with malice or willful intent to injure any person, provider, or insurer. (f) Nothing in this chapter abrogates the privileges and immunities established in IC 34-30-15 (or IC 34-4-12.6 before its repeal). (g) This subsection does not apply to a rate schedule maintained by state or federal government payers. An insurer that enters into an agreement with a provider under subsection (a)(1) must provide the provider a current reimbursement rate schedule: (1) every two (2) years; and (2) when three (3) or more CPT code (as defined in IC 27-1-37.5-3) rates under the agreement are changed in a twelve (12) month period. As added by P.L.140-1984, SEC.1. Amended by P.L.134-1994, SEC.1; P.L.191-1996, SEC.1; P.L.1-1998, SEC.151; P.L.1-1999, SEC.59; P.L.190-2023, SEC.29.

Ind. Code § 27-8-11-4 Accessibility and availability terms; reasonable standards

Sec. 4. Policies issued under section 3(a)(3) or section 3.1 of this chapter (before its repeal) may not contain terms or conditions that would operate unreasonably to restrict the access and availability of health care services for the insured. The commissioner of insurance may, under IC 4-22-2, adopt rules binding upon insurers prescribing reasonable standards relating to the accessibility and availability of health care services for persons insured under policies described in section 3(a)(3) or section 3.1 of this chapter (before its repeal). As added by P.L.140-1984, SEC.1. Amended by P.L.134-1994, SEC.3; P.L.1-1999, SEC.61.

Ind. Code § 27-8-11-4.5 Permitted disclosures by providers; coverage of benefit or service; payment of provider; application

Sec. 4.5. (a) An agreement between an insurer and provider under section 3 of this chapter may not prohibit a provider from disclosing: (1) financial incentives to the provider; (2) all treatment options available to an insured, including those not covered by the insured's policy. (b) An insurer may not penalize a provider financially or in any other manner for making a disclosure permitted under subsection (a). (c) An insured is not entitled to coverage of a benefit or service under a health insurance policy unless that benefit or service is included in the insured's health insurance policy. (d) A provider is not entitled to payment under a policy for benefits or services provided to an insured unless the provider has a contract or an agreement with the insurer. (e) This section applies to a contract entered, renewed, or modified after June 30, 1996. As added by P.L.192-1996, SEC.1.

Ind. Code § 27-8-11-5 Preferred provider plans; filing sworn statement

Sec. 5. Each person that organizes a preferred provider plan under this chapter shall file with the commissioner before March 1 of each year a statement, under oath, upon a form prescribed by the commissioner that covers the preceding calendar year and includes the following: (1) The name and address of each person that has organized a preferred provider plan. (2) The names and addresses of the providers with whom the preferred provider plan has entered into agreements under section 3 of this chapter. (3) The geographical area, by counties, within which the preferred provider plan provides or arranges for health care services for insureds, members or enrollees. (4) The number of insureds, members or enrollees covered by the agreements listed in subdivision (2). As added by P.L.31-1988, SEC.23.

Ind. Code § 27-8-11-6 Preferred provider plans; hospital accreditation

Sec. 6. (a) A preferred provider plan may not refuse to enter into an agreement with a hospital solely because the hospital has not obtained accreditation from an accreditation organization that: (1) establishes standards for the organization and operation of hospitals; (2) requires the hospital to undergo a survey process for a fee paid by the hospital; and (3) was organized and formed in 1951. (b) This section does not prohibit a preferred provider plan from using performance indicators or quality standards that: (1) are developed by private organizations; and (2) do not rely upon a survey process for a fee charged to the hospital to evaluate performance. As added by P.L.259-1995, SEC.2.

Ind. Code § 27-8-11-7 Applicability; credentialing; application; notification; response; status notification; provisional credential; retroactive reimbursement; termination

Sec. 7. (a) This section applies to an insurer that issues or administers a policy that provides coverage for basic health care services (as defined in IC 27-13-1-4). (b) As used in this section, "clean credentialing application" means an application for network participation that: (1) is submitted by a provider under this section; (2) does not contain an error; and (3) may be processed by the insurer without returning the application to the provider for a revision or clarification. (c) As used in this section, "credentialing" means a process by which an insurer makes a determination that: (1) is based on criteria established by the insurer; and (2) concerns whether a provider is eligible to: (A) provide health services to an individual eligible for coverage; and (B) receive reimbursement for the health services; under an agreement that is entered into between the provider and the insurer. (d) As used in this section, "unclean credentialing application" means an application for network participation that: (1) is submitted by a provider under this section; (2) contains at least one (1) error; and (3) must be returned to the provider to correct the error. (e) The department of insurance shall prescribe the credentialing application form used by the Council for Affordable Quality Healthcare (CAQH) in electronic or paper format, which must be used by: (1) a provider who applies for credentialing by an insurer; and (2) an insurer that performs credentialing activities. (f) An insurer shall notify a provider concerning a deficiency on a completed unclean credentialing application form submitted by the provider not later than five (5) business days after the entity receives the completed unclean credentialing application form. A notice described in this subsection must: (1) provide a description of the deficiency; and (2) state the reason why the application was determined to be an unclean credentialing application. (g) A provider shall respond to the notification required under subsection (f) not later than five (5) business days after receipt of the notice. (h) An insurer shall notify a provider concerning the status of the provider's completed clean credentialing application when: (1) the provider is provisionally credentialed; and (2) the insurer makes a final credentialing determination concerning the provider. (i) If the insurer fails to issue a credentialing determination within fifteen (15) business days after receiving a completed clean credentialing application form from a provider, the insurer shall provisionally credential the provider in accordance with the standards and guidelines governing provisional credentialing from the National Committee for Quality Assurance or its successor organization. The provisional credentialing license is valid until a determination is made on the credentialing application of the provider. (j) Once an insurer fully credentials a provider that holds provisional credentialing and a network provider agreement has been executed, then reimbursement payments under the contract shall be paid retroactive to the date the provider was provisionally credentialed. The insurer shall reimburse the provider at the rates determined by the contract between the provider and the insurer. (k) If an insurer does not fully credential a provider that is provisionally credentialed under subsection (i), the provisional credentialing is terminated on the date the insurer notifies the provider of the adverse credentialing determination. The insurer is not required to reimburse for services rendered while the provider was provisionally credentialed. As added by P.L.26-2005, SEC.2. Amended by P.L.195-2018, SEC.18; P.L.190-2023, SEC.30; P.L.17-2024, SEC.20; P.L.158-2024, SEC.23.

Ind. Code § 27-8-11-7.5 Provisional credentialing for independent primary care practice physicians; criteria

Sec. 7.5. (a) A physician licensed under IC 25-22.5 who was credentialed to provide services under Medicaid within the previous twelve (12) months shall be considered provisionally credentialed if the physician: (1) is in good standing with the office or a managed care organization or contractor of the office; and (2) establishes or joins an independent primary care practice. (b) The insurer shall complete the credentialing process for an individual who is provisionally credentialed under subsection (a). As added by P.L.203-2023, SEC.23.

Ind. Code § 27-8-11-8 Provider directories

Sec. 8. (a) An insurer may provide to an insured in electronic or paper form a directory of providers with which the insurer has entered into an agreement under section 3 of this chapter. (b) An insurer that provides a directory described in subsection (a) shall: (1) inform the insured that the insured may request the directory in paper form; and (2) provide the directory in paper form upon the request of the insured. As added by P.L.125-2005, SEC.5.

Ind. Code § 27-8-11-8.5 List of providers

Sec. 8.5. (a) As used in this section, "insurance producer" has the meaning set forth in IC 27-1-15.6-2. (b) An insurer shall provide any insurance producer who has contracted with the insurer with access to a complete list of every provider that has entered into an agreement with an insurer under section 3 of this chapter. (c) An insurer shall make the information described in subsection (b) available on the insurer's portal for insurance producer communications. As added by P.L.86-2026, SEC.26.

Ind. Code § 27-8-11-9 Preferred provider agreement prohibitions

Sec. 9. (a) As used in this section, "insurer" includes the following: (1) An administrator licensed under IC 27-1-25. (2) A person that pays or administers claims on behalf of an insurer. (b) An agreement between an insurer and a provider under this chapter 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. (c) A provision that: (1) is contained in an agreement between an insurer and a provider under this chapter; and (2) violates this section; is void. As added by P.L.74-2007, SEC.1.

Ind. Code § 27-8-11-10 Coverage for dialysis treatment

Sec. 10. (a) As used in this section, "dialysis facility" means an outpatient facility in Indiana at which a dialysis treatment provider provides dialysis treatment. (b) As used in this section, "contracted dialysis facility" means a dialysis facility that has entered into an agreement with a particular insurer under section 3 of this chapter. (c) Notwithstanding section 1 of this chapter, as used in this section, "insured" refers only to an insured who requires dialysis treatment. (d) As used in this section, "insurer" includes the following: (1) An administrator licensed under IC 27-1-25. (2) An agent of an insurer. (e) As used in this section, "non-contracted dialysis facility" means a dialysis facility that has not entered into an agreement with a particular insurer under section 3 of this chapter. (f) An insurer shall not require an insured, as a condition of coverage or reimbursement, to: (1) if the nearest dialysis facility is located within thirty (30) miles of the insured's home, travel more than thirty (30) miles from the insured's home to obtain dialysis treatment; or (2) if the nearest dialysis facility is located more than thirty (30) miles from the insured's home, travel a greater distance than the distance to the nearest dialysis facility to obtain dialysis treatment; regardless of whether the insured chooses to receive dialysis treatment at a contracted dialysis facility or a non-contracted dialysis facility. As added by P.L.111-2008, SEC.4.

Ind. Code § 27-8-11-11 Insurer payment to insured for service rendered by noncontracted provider; requirements

Sec. 11. (a) As used in this section, "noncontracted provider" means a provider that has not entered into an agreement with an insurer under section 3 of this chapter. (b) After September 30, 2009, if an insurer makes a payment to an insured for a health care service rendered by a noncontracted provider, the insurer shall include with the payment instrument written notice to the insured that includes the following: (1) A statement specifying the claims covered by the payment instrument. (2) The name and address of the provider submitting each claim. (3) The amount paid by the insurer for each claim. (4) Any amount of a claim that is the insured's responsibility. (5) A statement in at least 24 point bold type that: (A) instructs the insured to use the payment to pay the noncontracted provider if the insured has not paid the noncontracted provider in full; (B) specifies that paying the noncontracted provider is the insured's responsibility; and (C) states that the failure to make the payment violates the law and may result in collection proceedings or criminal penalties. As added by P.L.144-2009, SEC.2.

Ind. Code § 27-8-11-12 Right to provide prescription cost information; point of sale cost limit; pharmacist may not be required to collect higher copayment

Sec. 12. (a) As used in this section, "drug" means a prescription drug. (b) As used in this section, "insurer" refers to an insurer that provides coverage for drugs. The term includes a person that administers drug benefits on behalf of an insurer. (c) As used in this section, "pharmacy" refers to a pharmacist or pharmacy that has entered into an agreement with an insurer under section 3 of this chapter. (d) A pharmacy or pharmacist shall have the right to provide an insured with information concerning the amount of the insured's cost share for a prescription drug. Neither a pharmacy nor a pharmacist shall be proscribed by an insurer from discussing this information or from selling to the insured a more affordable alternative if an affordable alternative is available. (e) An insurer that covers prescription drugs may not include a provision that requires an insured to make payment for a prescription drug at the point of sale in an amount that exceeds the lesser of: (1) the contracted copayment amount; or (2) the amount of total approved charges by the insurer at the point of sale. This subsection does not prohibit the adjudication of claims in accordance with an accident and sickness insurance policy issued or administered by an insurer. The insured is not liable for any additional charges or entitled to any credits as a result of the adjudicated claim. (f) The insurer or a pharmacy benefit manager may not require a pharmacy or pharmacist to collect a higher copayment for a prescription drug from an insured than the insurer or pharmacy benefit manager allows the pharmacy or pharmacist to retain. As added by P.L.209-2018, SEC.12. Amended by P.L.114-2020, SEC.20; P.L.9-2022, SEC.52.

Ind. Code § 27-8-11-13 Fully credentialed provider reimbursement; requirements

Sec. 13. (a) A fully credentialed provider shall be reimbursed for eligible services provided at any in-network hospital if the following conditions are met: (1) The provider submits the documentation required by the insurer to be loaded under the provider group or hospital. (2) The provider, provider group, or hospital is a network provider with the insurer. (3) The services are provided in accordance with all terms and conditions of the provider's, group provider's, or hospital's agreement or contract with the insurer. (4) Prior authorization is obtained in accordance with IC 27-1-37.5 when required by the insurer for an eligible service. (b) The insurer shall reimburse the provider or hospital for services described in subsection (a) at the rates determined by the contract between the provider and the insurer. (c) An insurer is not required to credential a provider. However, if: (1) a provider is employed by a hospital that is part of the hospital's network that is covered by the insurer; and (2) the provider meets the insurer's credentialing requirements; the insurer shall reimburse the provider for any reimbursable services from the date that the provider was employed by the hospital. As added by P.L.50-2020, SEC.8.

Ind. Code § 27-8-11-13.5 Provisional credentialing for physicians; conditions

Sec. 13.5. (a) As used in this section, "physician" refers to an individual who: (1) is licensed under IC 25-22.5; (2) has been granted reciprocity by the medical licensing board of Indiana under IC 25-1-21 before July 1, 2026; or (3) is licensed in a state that has enacted the interstate medical licensure compact. (b) If a physician who is fully credentialed by an insurer: (1) leaves the employment of an employer and becomes employed with another employer in Indiana; or (2) establishes or relocates a medical practice in Indiana; the insurer shall provisionally credential the physician for the time frame set forth in subsection (c). (c) A physician under subsection (b) must be provisionally credentialed: (1) for sixty (60) days after the physician's separation from employment or the establishment or relocation of the medical practice; or (2) until the physician is fully credentialed by the insurer; whichever is earlier. (d) Notwithstanding section 7(k) of this chapter, an insurer shall reimburse a physician who is provisionally credentialed under this section for services rendered while the physician was provisionally credentialed at the rates determined by: (1) the agreement between the physician's new employer and the insurer under section 3 of this chapter; or (2) if: (A) the physician's new employer has not entered into an agreement with the insurer under section 3 of this chapter; or (B) the physician established or relocated a medical practice; the agreement between the physician and the insurer under section 3 of this chapter that was in effect at the time of the physician's separation from employment or the establishment or relocation of the medical practice. As added by P.L.215-2025, SEC.64.

Ind. Code § 27-8-11-14 Definitions; assignment of benefits; direct payment to provider; payment in full

Sec. 14. (a) As used in this section, "covered individual" means an individual who is entitled to the coverage of dental services by a dental carrier. (b) As used in this section, "dental carrier" means any of the following: (1) An insurer that issues a policy of accident and sickness insurance that covers dental services. (2) A health maintenance organization that provides, or provides coverage for, dental services. (3) A preferred provider plan subject to this chapter under which dental services are provided. (c) As used in this section, "dental services" means health care services provided by: (1) a dentist licensed under IC 25-14; (2) an individual using a dental residency permit issued under IC 25-14-1-5; (3) an individual who holds: (A) a dental faculty license under IC 25-14-1-5.5; or (B) an instructor's license under IC 25-14-1-27.5; (4) a dental hygienist licensed under IC 25-13; or (5) a dental assistant (as defined in IC 25-14-1-1.5(4)); within the scope of the individual's license or work description in IC 25-13 or IC 25-14, as appropriate. However, the term does not include a service delivered by a provider if the service is billed as a medical expense. (d) As used in this section, "network" means all providers that have entered into a contract with a dental carrier under which the providers agree to charge no more than a certain amount for certain dental services provided to covered individuals who are entitled to the coverage of dental services by the dental carrier. (e) As used in this section, "provider" means: (1) a dentist licensed under IC 25-14; or (2) a dental office through which one (1) or more dentists licensed under IC 25-14 provide dental services. (f) If a covered individual assigns the rights of the covered individual to benefits for dental services to the provider of the dental services, the covered individual's dental carrier shall pay the benefits assigned by the covered individual to the provider of the dental services. (g) A dental carrier shall make a payment under this section: (1) directly to the provider of the dental services; and (2) according to the same criteria and payment schedule under which the dental carrier would have been required to make the payment to the covered individual if the insured had not assigned the insured's rights to the benefits. (h) An assignment of benefits under this section does not affect or limit the dental carrier's obligation to pay the benefits. (i) A dental carrier's payment of benefits in compliance with this section discharges the dental carrier's obligation to pay the benefits to the insured. (j) If: (1) a covered individual is entitled to coverage from a dental carrier; (2) the covered individual is provided dental services by a provider; (3) the covered individual assigns the covered individual's rights to benefits from the dental carrier to the provider of the dental services; and (4) the provider of the dental services is a member of the network of the dental carrier; the provider shall accept compensation from the dental carrier in the amount specified in the network contract as payment in full for the dental services provided to the covered individual and shall not bill the covered individual for the dental services, except for copayments, coinsurance and any deductible amount that remains after the dental carrier's payment for the dental services. As added by P.L.17-2024, SEC.21.
Source: Open US Law by Vaquill AI (CC BY 4.0)URL: https://iga.in.gov/laws/2026/ic/titles/27Fetched: 10/17/2026

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