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27-1-37.5-13. Unanticipated, medically necessary health care service; denial; payment for health care service with prior authorization

IN Code § 27-1-37.5-13 (2019) (N/A)
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Sec. 13. (a) This section applies to a claim filed after December 31, 2018, for a medically necessary health care service rendered by a participating provider, the necessity of which:

(1) is not anticipated at the time prior authorization is obtained for another health care service; and

(2) is determined at the time the other health care service is rendered.

(b) The health plan shall not deny a claim described in subsection (a) based solely on lack of prior authorization for the unanticipated health care service.

(c) The health plan:

(1) shall not deny payment for a health care service that is rendered in accordance with:

(A) a prior authorization; and

(B) all terms and conditions of the participating provider's agreement or contract with the health plan; and

(2) may:

(A) require retrospective review of; and

(B) withhold payment for;

an unanticipated health care service described in subsection (a).

As added by P.L.77-2018, SEC.2.

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