Submitting claims data; requirements; compliance with federal law

Sec. 1. (a) Not more than four (4) times per calendar year for a contract holder, a third party administrator, an insurer (as defined in IC 27-1-2-3(x)) that issues a policy of accident and sickness insurance (as defined in IC 27-8-5-1(a)), or a health maintenance organization (as defined in IC 27-13-1-19) that has contracted to administer a self-funded group plan or a fully insured group plan shall provide claims data to the contract holder for which the contract was entered into not later than fifteen (15) business days from a request for the claims data. The claims data must include the following:

(1) The effective date of coverage.

(2) The total number of covered individuals.

(3) The total monthly earned premium.

(4) The total monthly dollar value of paid claims, regardless of the period in which the claims were incurred.

(5) The:

(A) beginning and ending date of the period for which claims were paid; and

(B) percentage of claims that were paid in:

(i) less than thirty (30) days;

(ii) thirty (30) days to sixty (60) days;

(iii) sixty-one (61) days to ninety (90) days; and

(iv) over ninety (90) days.

(6) For groups insuring at least one hundred (100) employees:

(A) the reserve value as of the beginning of the period; and

(B) the reserve value as of the date through which the paid claims data was obtained.

(7) A description of each large or catastrophic claim exceeding fifty thousand dollars ($50,000), including:

(A) the diagnosis;

(B) the dollar amount of the claim;

(C) whether the claim is opened or closed; and

(D) the length of time the claim was open.

(8) Any other claims data requested by the contract holder.

(b) The department may prescribe the format and manner for the submission of the data described in subsection (a) with the purpose of ensuring that the information is provided in an easily readable manner.

(c) Information provided under this section must be provided in accordance with the federal Health Insurance Portability and Accountability Act, including 45 CFR Part 160 and Part 164, Subparts A and E.

(d) The department shall perform an examination under IC 27-1-3.1 for any alleged violation of this section.

As added by P.L.203-2023, SEC.22. Amended by P.L.216-2025, SEC.48.