IN HMO Affidavit – Interest Owed on Late Claims
Last Updated: November 21, 2021 | Letter Type: Affidavits | Jurisdiction: IN HMOs
AFFIDAVIT OF COMPLIANCE Interest Owed on Late Claims Incorporated by Reference in 28 US Code § 1746 Patient/Multiple Patients: DOS: I hereby certify that I have collected, verified, and am maintaining on file evidence that the below Health Plan or Contracted Entity has met the provisions of... View more
IN HMO Affidavit – Maternity Coverage
Last Updated: November 21, 2021 | Letter Type: Affidavits | Jurisdiction: IN HMOs
AFFIDAVIT OF COMPLIANCE Maternity Services Incorporated by Reference in 28 US Code § 1746 Patient/Multiple Patients: DOS: I hereby certify that I have collected, verified, and am maintaining on file evidence that the below Health Plan or Contracted Entity has met the provisions of IN Code §27-8-24-4,... View more
IN HMO Affidavit – Medical Necessity – Qualified Reviewers
Last Updated: November 21, 2021 | Letter Type: Affidavits | Jurisdiction: IN HMOs
AFFIDAVIT OF COMPLIANCE Medical Necessity – Competent Reviewer Incorporated by Reference in 28 US Code § 1746 Patient/Multiple Patients: DOS: I hereby certify that I have collected, verified, and am maintaining on file evidence that the below Health Plan or Contracted Entity has met the provisions of... View more
IN HMO Affidavit – No Authorization for ER Services and Care
Last Updated: November 20, 2021 | Letter Type: Affidavits | Jurisdiction: IN HMOs
AFFIDAVIT OF COMPLIANCE Emergency and Urgently Needed Services Incorporated by Reference in 28 US Code § 1746 Patient/Multiple Patients: DOS: I hereby certify that I have collected, verified, and am maintaining on file evidence that the below Health Plan or Contracted Entity has met the provisions of... View more
IN HMO Affidavit – Non-urgent Authorization Timeframes
Last Updated: November 21, 2021 | Letter Type: Affidavits | Jurisdiction: IN HMOs
AFFIDAVIT OF COMPLIANCE Timeframes for Authorization Requests – Non-Urgent Health Services Incorporated by Reference in 28 US Code § 1746 Patient/Multiple Patients: DOS: I hereby certify that I have collected, verified, and am maintaining on file evidence that the below Health Plan or Contracted Entity has met... View more
IN HMO Affidavit – Notice Requirements for Adverse Determinations
Last Updated: November 20, 2021 | Letter Type: Affidavits | Jurisdiction: IN HMOs
AFFIDAVIT OF COMPLIANCE Notice Requirements for Adverse Determinations Incorporated by Reference in 28 US Code § 1746 Patient/Multiple Patients: DOS: I hereby certify that I have collected, verified, and am maintaining on file evidence that the below Health Plan or Contracted Entity has met the provisions of... View more
IN HMO Affidavit – Poststabilization Timeframe
Last Updated: October 8, 2021 | Letter Type: Affidavits | Jurisdiction: IN HMOs
AFFIDAVIT OF COMPLIANCE Poststabilization Care Services Incorporated by Reference in 28 US Code § 1746 Patient/Multiple Patients: DOS: I hereby certify that I have collected, verified, and am maintaining on file evidence that the below Health Plan or Contracted Entity has met the provisions of IN Code... View more
IN HMO Affidavit – Refund Recoupment
Last Updated: October 8, 2021 | Letter Type: Affidavits | Jurisdiction: IN HMOs
AFFIDAVIT OF COMPLIANCE Refund Recoupment Incorporated by Reference in 28 US Code § 1746 Patient/Multiple Patients: DOS: I hereby certify that I have collected, verified, and am maintaining on file evidence that the below Health Plan or Contracted Entity has met the provisions of IN Code §27-8-5.7-10(a),... View more
IN HMO Affidavit – Retroactive Denial for Authorized Care
Last Updated: November 20, 2021 | Letter Type: Affidavits | Jurisdiction: IN HMOs
AFFIDAVIT OF COMPLIANCE Retroactive Denial of Authorized Services Incorporated by Reference in 28 US Code § 1746 Patient/Multiple Patients: DOS: I hereby certify that I have collected, verified, and am maintaining on file evidence that the below Health Plan or Contracted Entity has met the provisions of... View more
IN HMO Affidavit – Untimely Payment
Last Updated: November 20, 2021 | Letter Type: Affidavits | Jurisdiction: IN HMOs
AFFIDAVIT OF COMPLIANCE Prompt Payment to Providers Incorporated by Reference in 28 US Code § 1746 Patient/Multiple Patients: DOS: I hereby certify that I have collected, verified, and am maintaining on file evidence that the below Health Plan or Contracted Entity has met the provisions of IN... View more