Ind. Code § 27-1-52-0.3 Applicability
Sec. 0.3. This chapter does not apply to the Medicaid program or a managed care organization (as defined in IC 12-7-2-126.9) that provides services to a Medicaid recipient.
As added by P.L.88-2026, SEC.6.
Ind. Code ch. 27-1-52
Ind. Code ch. 27-1-52
in effectInd. Code § 27-1-52-0.5 "CARC"
Sec. 0.5. As used in this chapter, "CARC" refers to the claim adjustment reason codes that provide the reason for a financial adjustment specified to a particular claim or service, as referenced in the transmitted Accredited Standards Committee (ASC) X12 835 standard transaction adopted by the Department of Health and Human Services under 45 CFR 162.1602.
As added by P.L.88-2026, SEC.6.
Ind. Code § 27-1-52-1 "Covered individual"
Sec. 1. As used in this chapter, "covered individual" means an individual who is entitled to coverage under a health plan.
As added by P.L.88-2026, SEC.6.
Ind. Code § 27-1-52-2 "Downcode"; "downcoding"
Sec. 2. As used in this chapter, "downcode" or "downcoding" means the unilateral alteration by an insurer of the:
(1) payment for an evaluation and management service code or other service code; or
(2) level of evaluation and management service code or other service code submitted on a claim that results in a lower payment.
As added by P.L.88-2026, SEC.6.
Ind. Code § 27-1-52-3 "Health benefits claim"
Sec. 3. As used in this chapter, "health benefits claim" means a claim submitted by a provider for payment under a health plan for health care services provided to a covered individual.
As added by P.L.88-2026, SEC.6.
Ind. Code § 27-1-52-4 "Health care service"
Sec. 4. As used in this chapter, "health care service" means a service or good furnished for the purpose of preventing, alleviating, curing, or healing:
(1) human illness;
(2) physical disability; or
(3) injury.
As added by P.L.88-2026, SEC.6.
Ind. Code § 27-1-52-5 "Health plan"
Sec. 5. As used in this chapter, "health plan" means the following:
(1) A policy of accident and sickness insurance (as defined in IC 27-8-5-1).
(2) An individual contract (as defined in IC 27-13-1-21) or a group contract (as defined in IC 27-13-1-16) with a health maintenance organization (as defined in IC 27-13-1-19).
(3) A preferred provider plan subject to IC 27-8-11 under which dental services are provided.
As added by P.L.88-2026, SEC.6.
Ind. Code § 27-1-52-6 "Insurer"
Sec. 6. As used in this chapter, "insurer" means the following:
(1) An insurer (as defined in IC 27-1-2-3(x)) that issues a policy of accident and sickness insurance (as defined in IC 27-8-5-1).
(2) A health maintenance organization (as defined in IC 27-13-1-19) that provides coverage for basic health care services (as defined in IC 27-13-1-4) under an individual contract (as defined in IC 27-13-1-21) or a group contract (as defined in IC 27-13-1-16).
(3) An insurer that enters into a preferred provider plan subject to IC 27-8-11 under which dental services are provided.
(4) A third party contractor of an entity described in subdivision (1), (2), or (3).
As added by P.L.88-2026, SEC.6.
Ind. Code § 27-1-52-7 "Provider"
Sec. 7. As used in this chapter, "provider" means an individual or entity licensed or legally authorized to provide health care services.
As added by P.L.88-2026, SEC.6.
Ind. Code § 27-1-52-7.5 "RARC"
Sec. 7.5. As used in this chapter, "RARC" refers to remittance advice remark codes that provide:
(1) supplemental information about a financial adjustment indicated by a CARC; or
(2) information about remittance processing.
As added by P.L.88-2026, SEC.6.
Ind. Code § 27-1-52-8 Limitation on use of downcoding by insurer
Sec. 8. Notwithstanding any other law or regulation to the contrary, an insurer may not use downcoding in a manner that prevents a provider from:
(1) submitting a health benefits claim for the actual health care service performed; and
(2) collecting reimbursement from the insurer for the actual health care service performed.
As added by P.L.88-2026, SEC.6.
Ind. Code § 27-1-52-9 Limitation on use of automated process, system, or tool
Sec. 9. (a) An insurer may not use an automated:
(1) process;
(2) system; or
(3) tool, including artificial intelligence;
as the sole basis to downcode a claim based on medical necessity without the review of the covered individual's medical record by an employee or contractor of the insurer.
(b) A provider may not use an automated:
(1) process;
(2) system; or
(3) tool, including artificial intelligence;
to submit a health benefits claim without the review of a provider or other person involved in the development of the claim for submission.
(c) An insurer must disclose in an easily accessible and readable manner when artificial intelligence is used to:
(1) make an adverse determination on a prior authorization request; or
(2) downcode a claim.
As added by P.L.88-2026, SEC.6.
Ind. Code § 27-1-52-10 Prohibition on downcoding based on reported diagnosis code
Sec. 10. An insurer may not downcode a claim based solely on the reported diagnosis code.
As added by P.L.88-2026, SEC.6.
Ind. Code § 27-1-52-11 Notice requirement
Sec. 11. If a claim is downcoded, the insurer shall:
(1) notify the provider using the appropriate CARC and RARC to clearly indicate that the claim has been downcoded; and
(2) provide:
(A) the specific reason for the downcoding, including reference to the clinical criteria used to justify the downcoding;
(B) the original and revised service codes and payment amounts; and
(C) a notice of the right to appeal as described in section 12 of this chapter.
As added by P.L.88-2026, SEC.6.
Ind. Code § 27-1-52-12 Appeal process
Sec. 12. (a) An insurer shall provide providers with a clear and accessible process for appealing downcoded claims, including:
(1) a written or electronic notice detailing how to initiate an appeal;
(2) contact information for the individual managing the appeal; and
(3) a timeline for submission of an appeal that is not less than one hundred eighty (180) days.
(b) An insurer shall allow a provider to appeal in batches of similar claims involving substantially similar downcoding issues without restriction.
As added by P.L.88-2026, SEC.6.
Ind. Code § 27-1-52-13 Prohibition on downcoding in targeted or discriminatory manner
Sec. 13. An insurer may not downcode in a targeted or discriminatory manner against providers that routinely treat patients with complex or chronic conditions.
As added by P.L.88-2026, SEC.6.
Ind. Code § 27-1-52-14 Rules
Sec. 14. The department shall adopt rules under IC 4-22-2 to carry out this chapter.
As added by P.L.88-2026, SEC.6.
Source: Open US Law by Vaquill AI (CC BY 4.0)URL: https://iga.in.gov/laws/2026/ic/titles/27Fetched: 10/17/2026