If you are an insurer, health maintenance organization (HMO), employer, or anyone responsible for paying for health care services, you can submit a complaint if there’s an issue with how a bill for health care services from a qualified provider was submitted.
Additionally, if you are a hospital that is part of an “Indiana Non-Profit Hospital System,” as that term is defined in Indiana Code 16-51-1-4, you may submit a complaint if you believe a claim submitted on an institutional provider form was correctly submitted but wrongfully denied or offset by an insurer.
Here’s what you need to know:
1. What is the complaint about?
A complaint can be made if a bill for health care services provided in an office setting by a qualified provider was submitted on an institutional claim (e.g., UB-04) form when it should have been submitted on an individual claim form (e.g. CMS-1500)
Likewise, a complaint can be made if a bill for health care services provided in an office setting by a qualified provider was submitted correctly on an institutional provider form but improperly denied or offset.
2. Who is a “qualified provider”?
A qualified provider is someone who:
- Is licensed to provide health care services.
- Is an employee of an Indiana non-profit hospital system or an entity owned, in whole or in part, by an Indiana non-profit hospital system
3. What is an “office setting”?
An office setting is a location where health care services are provided that:
- Is located more than 250 yards from the main building of a hospital owned by an Indiana nonprofit hospital system.
- Is where health care services such as exams, diagnoses, or non-invasive treatments are regularly done.
4. What is an “Indiana non-profit hospital system?”
An Indiana Non-Profit Hospital System means a hospital that:
(1) is organized as a nonprofit corporation or a charitable trust under Indiana law or the laws of any other state or country and that is:
(A) eligible for tax exempt bond financing; or
(B) exempt from state or local taxes;
(2) is licensed under Indiana Code 16-21-2;
(3) filed jointly one (1) hospital audited financial statement with the Indiana department of health in 2021; and
(4) has an annual patient service revenue of at least two billion dollars ($2,000,000,000) based on the hospital system's 2021 audited financial statement filed with the Indiana department of health. As used here, "patient service revenue" includes similar terms, including net patient service revenue and patient care service revenue.
5. What happens if the complaint is about a wrong billing form?
If a health care service bill is submitted incorrectly (using the wrong form), it should not be accepted by the insurer or person paying for the service.
If you’re facing issues with a bill that was submitted incorrectly or one that was improperly denied, you can file a complaint about it here.
The full text of the law, including definitions, can be found here: Indiana Code 16-51.