5-3) submitted for a clean claim or pay for a CPT code (as defined in IC 27-1-37.5-3) of lesser monetary value unless:(1) the CPT code submitted is not in accordance with correct coding guidelines and rules, clinical care guidelines, or the terms and conditions of the participating provider's agreement or contract with the health maintenance organization; or(2) the medical record of the clean claim has been reviewed by an employee or contractor of the health maintenance organization.(b) A health maintenance organization may not alter a clean claim to only pay for the CPT codes (as defined in IC 27-1-37.5-3) necessary for an individual's final diagnosis, if the CPT codes (as defined in IC 27-1-37.5-3) billed were deemed medically necessary according to generally accepted clinical care guidelines to reach the final diagnosis.(c) This section does not prohibit a provider from appealing a claim.As added by P.L.190-2023, SEC.35.
Indiana Legal Code