760 IAC 1-23-2 Approved forms

Sec. 2. All accident and sickness insurers, hospitals, medical and dental service corporations, and other prepayment organizations must accept forms approved by this Department for the administration of benefit payments. It is the opinion of the Commissioner that the interests of the insuring public would be best served by adoption of forms developed for nationwide use by national health care provider organizations, health insurers and other prepayment organizations. Accordingly, the following forms are hereby adopted and approved for use in this state: ATTENDING DENTIST'S STATEMENT – ADS (75), (Exhibit 1), developed under the auspices of the American Dental Association by its Task Force representing dental insurance underwriters. HEALTH INSURANCE CLAIM FORM – 6-74, (Exhibit II), developed under the auspices of an [sic.] approved by the American Medical Association by its WORK GROUP on attending physician's billing and insurance reporting forms representing health insurers. UNIFORM HOSPITAL BILLING FORM – UB-82 HCFA-1450, (Exhibit III), developed under the auspices of the Health Care Financing Administration of the Department of Health and Human Services. LONG-TERM DISABILITY INCOME – APS-LT/P&T DIS (75), (Exhibit IV), developed by the Standard Forms Committee of the Health Insurance Association of American Council on Consumer and Professional Relations and approved by the American Medical Association Committee on Health Care Financing. VISION INSURANCE CLAIM FORM – VICF (75), (Exhibit V), developed by the Standard Forms Committee of the Health Insurance Association of American Council on Consumer and Professional Relations and approved by the American Optometric Association.