Section 405 IAC 1-1-16 - Insurance information; releaseAuthority: IC 12-15-1-10; IC 12-15-1-15; IC 12-15-21-2
Affected: IC 12-13-7-3; IC 12-15-29
Sec. 16.
(a) "Insurer" means any insurance company, 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 plans, union welfare plans, employer organization plans, employee benefit organization plans, governmental program plans, fraternal benefits societies, any plan or coverage required or provided by any statute, or similar entity that: (1) is doing business in this state; and(2) is under an obligation to make payments for medical services as a result of an injury, illness, or disease suffered by a Medicaid member.(b) In accordance with IC 12-15-29-1, a Medicaid applicant or member or one legally authorized to seek Medicaid 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 or benefits, or both, 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 Medicaid. Information, to the extent available, regarding the insured may include, but need not be limited to:(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 which 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, life time days, life time funds;(7) the deductible, and the amount of deductible outstanding for each benefit at the time of the request;(8) any additional coinsurance information which 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 or provider, or both;(11) other policy information which the office certifies in writing is necessary to secure and enforce its rights pertaining to third party liability collection;(12) carrier information, including: (A) name and address of carrier;(B) adjustor's name and address; and(C) policy number or claim number, or both; and(13) claims information, including: (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 said services, if necessary for claims processing;(D) date on which said services were rendered; and(E) a detailed explanation of charges and benefits.Office of the Secretary of Family and Social Services; 405 IAC 1-1-16; filed Sep 29, 1982, 3:21 pm: 5 IR 2320; readopted filed Jun 27, 2001, 9:40 a.m.: 24 IR 3822; readopted filed Sep 19, 2007, 12:16p.m.: 20071010-IR-405070311RFA; readopted filed Oct 28, 2013, 3:18 p.m.: 20131127-IR-405130241RFAFiled 8/1/2016, 3:44 p.m.: 20160831-IR-405150418FRAErrata filed 10/6/2016, 2:59 p.m.: 20161019-IR-405160452ACAReadopted filed 7/28/2022, 2:21 p.m.: 20220824-IR-405220205RFAReadopted filed 5/30/2023, 11:54 a.m.: 20230628-IR-405230292RFA Transferred from the Division of Family and Children (470 IAC 5-1-14) to the Office of the Secretary of Family and Social Services (405 IAC 1-1-16) by P.L. 9-1991, SECTION 131, effective January 1, 1992.