HB 1300-2_ Filed 03/30/2009, 10:57 Miller

SENATE MOTION


MADAM PRESIDENT:

    I move
that Engrossed House Bill 1300 be amended to read as follows:

SOURCE: Page 2, line 8; (09)MO130008.2. -->     Page 2, between lines 8 and 9, begin a new paragraph and insert:
SOURCE: IC 27-8-5.9; (09)MO130008.2. -->     "SECTION 2. IC 27-8-5.9 IS ADDED TO THE INDIANA CODE AS A NEW CHAPTER TO READ AS FOLLOWS [EFFECTIVE JULY 1, 2009]:
     Chapter 5.9. Assignment of Benefits
    Sec. 1. The definitions in IC 27-8-11-1 apply throughout this chapter.
    Sec. 2. As used in this chapter, "contracted provider" means a provider that has entered into an agreement with an insurer under IC 27-8-11-3.
    Sec. 3. As used in this chapter, "covered individual" means an individual who is entitled to coverage under a policy.
    Sec. 4. As used in this chapter, "emergency" means a medical condition that arises suddenly and unexpectedly and manifests itself by acute symptoms of such severity, including severe pain, that the absence of immediate medical attention could reasonably be expected by a prudent layperson who possesses an average knowledge of health and medicine to:
        (1) place an individual's health in serious jeopardy;
        (2) result in serious impairment to the individual's bodily functions; or
        (3) result in serious dysfunction of a bodily organ or part of the individual.
    Sec. 5. As used in this chapter, "health care services" includes ambulance services.
    Sec. 6. As used in this chapter, "noncontracted provider" means a provider that has not entered into an agreement with an insurer under IC 27-8-11-3.
    Sec. 7. (a) Except as provided in subsection (b), if a policy provides coverage for a health care service that is rendered by a noncontracted provider:
        (1) who renders the health care service on an emergency basis in a hospital or an ambulatory outpatient surgical center and submits a claim for the health care service on the appropriate insurer claim form;
        (2) who renders the health care service as:
            (A) an anesthesiologist;
            (B) a pathologist; or
            (C) a radiologist;
        in a hospital or an ambulatory outpatient surgical center with which the insurer has entered into a contract under IC 27-8-11-3; or
        (3) that is chosen by a provider described in subdivision (1) or (2) without the specific consent of the covered individual;
the insurer shall make a benefit payment directly to the noncontracted provider for the health care service and send written notice of the payment to the covered individual or the authorized representative of the covered individual.
    (b) An insurer is not required to make a benefit payment directly to a noncontracted provider described in subsection (a) if the noncontracted provider has been convicted of fraud.
    (c) This section does not require:
        (1) coverage for benefits not covered under the terms of a policy; or
        (2) payment to a noncontracted provider that is not eligible for a benefit payment under the terms of a policy.
    Sec. 8. If:
        (1) a noncontracted provider is entitled to a direct benefit payment under section 7 of this chapter; and
        (2) there is a good faith dispute regarding the:
            (A) legitimacy of the claim relating to the health care service rendered;
            (B) appropriate amount of reimbursement for the claim; or
            (C) authorization for the assignment of benefits;
the insurer, not more than fourteen (14) business days after the insurer receives the claim and all documentation reasonably necessary to determine claim payment, shall provide notice of the dispute to the noncontracted provider or the noncontracted provider's authorized representative.

SOURCE: IC 27-13-36.3; (09)MO130008.3. -->     SECTION 3. IC 27-13-36.3 IS ADDED TO THE INDIANA CODE AS A NEW CHAPTER TO READ AS FOLLOWS [EFFECTIVE JULY 1, 2009]:
    Chapter 36.3. Payment to Nonparticipating Providers
    Sec. 1. As used in this chapter, "health care services", in addition to having the meaning set forth in IC 27-13-1-18, includes ambulance services.
    Sec. 2. As used in this chapter, "health maintenance organization", in addition to having the meaning set forth in

IC 27-13-1-19, includes a limited service health maintenance organization.
    Sec. 3. As used in this chapter, "nonparticipating provider" means a provider that has not entered into an agreement described in IC 27-13-1-24.
    Sec. 4. As used in this chapter, "provider", in addition to having the meaning set forth in IC 27-13-1-28, includes an ambulance service provider.
    Sec. 5. Except as provided in subsection (b), if an individual contract or a group contract provides coverage for a health care service that is rendered by a nonparticipating provider:
        (1) who renders the health care service on an emergency basis in a hospital or an ambulatory outpatient surgical center and submits a claim for the health care service on the appropriate claim form;
        (2) who renders the health care service as:
            (A) an anesthesiologist;
            (B) a pathologist; or
            (C) a radiologist;
        in a hospital or an ambulatory outpatient surgical center that is a participating provider; or
        (3) that is chosen by a provider described in subdivision (1) or (2) without the specific consent of the enrollee;
the health maintenance organization shall make a benefit payment directly to the nonparticipating provider for the health care service and send written notice of the payment to the enrollee or the authorized representative of the enrollee.
    (b) A health maintenance organization is not required to make a benefit payment directly to a nonparticipating provider described in subsection (a) if the nonparticipating provider has been convicted of fraud.
    (c) This section does not require:
        (1) coverage for benefits not covered under the terms of an individual contract or a group contract; or
        (2) payment to a nonparticipating provider that is not eligible for a benefit payment under the terms of an individual contract or a group contract.
    Sec. 6. If:
        (1) a nonparticipating provider is entitled to a direct benefit payment under section 5 of this chapter; and
        (2) there is a good faith dispute regarding the:
            (A) legitimacy of the claim relating to the services rendered;
            (B) appropriate amount of reimbursement for the claim; or
            (C) payment of the claim under the terms of the individual contract or group contract;
the health maintenance organization, not more than fourteen (14)

business days after the health maintenance organization receives the claim and all documentation reasonably necessary to determine claim payment, shall provide notice of the dispute to the nonparticipating provider or the nonparticipating provider's authorized representative.".
    Renumber all SECTIONS consecutively.
    (Reference is to EHB 1300 as printed March 27, 2009.)

________________________________________

Senator MILLER


MO130008/DI 97
2009