407 IAC 1-2-7 - Insurance information; release
Authority: IC 12-17.6-2-11
Affected: IC 12-17.6
Sec. 7.
(a) As used
in this section, "insurer" means any insurance company, health maintenance
organization, prepaid health care delivery plan, self-funded employee benefit
plan, pension fund, retirement system, group coverage plan, blanket coverage
plan, franchise insurance coverage plan, individual coverage plan, family-type
insurance coverage plan, Blue Cross/Blue Shield plan, group practice plan,
individual practice plan, labor-management trusteed plan, union welfare plan,
employer organization plan, employee benefit organization plan, governmental
program plan, fraternal benefits society, Indiana Comprehensive Health
Insurance Association plan, any plan or coverage required or provided by any
statute, or similar entity that is:
(1) doing
business in this state; and
(2)
under an obligation to make payments for medical services as a result of an
injury, illness, or disease suffered by a CHIP member.
(b) A CHIP applicant or member or one legally
authorized to seek CHIP benefits on behalf of the applicant or member shall be
considered to have authorized all insurers to release to the office all
available information needed by the office to secure or enforce its rights
pertaining to third party liability collection.
(c) Every insurer shall provide to the
office, upon written request, information pertaining to coverage and benefits
paid or available to an individual under an individual, group, or blanket
policy or certificate of coverage when the office certifies that such
individual is an applicant for or a member of CHIP. Information, to the extent
available, regarding the insured may include, but need not be limited to, the
following:
(1) Name, address, and Social
Security number of the insured.
(2)
Policy numbers, the terms of the policy, and the benefit code.
(3) Names of covered dependents whom the
state certifies are applicants or members.
(4) Name and address of employer, other
person, or organization that holds the group policy.
(5) Name and address of employer, other
person, or organization through which the coverage was obtained.
(6) Benefits remaining available under the
policy, including, but not limited to, coverage periods, lifetime days, and
lifetime funds.
(7) The deductible
and the amount of deductible outstanding for each benefit at the time of the
request.
(8) Any additional
coinsurance information that may be on file.
(9) Copies of claims when requested for legal
proceedings.
(10) Copies of checks
and their endorsements when these documents are needed as part of an
investigation of a member and provider.
(11) Other policy information that the office
certifies in writing is necessary to secure and enforce its rights pertaining
to third party liability collection.
(12) Carrier information, including the
following:
(A) Name and address of
carrier.
(B) Adjuster's name and
address.
(C) Policy number and
claim number.
(13)
Claims information, including the following:
(A) Identity of the individual to whom the
service was rendered.
(B) Identity
of the provider rendering services.
(C) Identity and position of provider's
employee rendering the services, if necessary for claims processing.
(D) Date on which services were
rendered.
(E) A detailed
explanation of charges and benefits.
Notes
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