IC 27-13-43-4: Fully credentialed provider reimbursement; requirements

Sec. 4. (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 health maintenance organization to be loaded under the provider group or hospital.

(2) The provider, provider group, or hospital is a network provider with the health maintenance organization.

(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 health maintenance organization.

(4) Prior authorization is obtained in accordance with IC 27-1-37.5 when required by the health maintenance organization for an eligible service.

(b) The health maintenance organization shall reimburse the provider or hospital for services described in subsection (a) at the rates determined by the contract between the provider and the health maintenance organization.

(c) A health maintenance organization 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 health maintenance organization; and

(2) the provider meets the health maintenance organization's credentialing requirements;

the health maintenance organization shall reimburse the provider for any reimbursable services from the date that the provider was employed by the hospital.