Document kit · Indiana

Build the paper trail before you pay.

Keep these documents yourself and submit them only to your health plan through the process it confirms. KnownCost never collects this kit.

1 · Good Faith Estimate

Get the all-in price in writing.

Ask for facility and professional fees, reads, contrast, draw fees, and the CPT codes. If care is scheduled at least 3 business days ahead, the estimate is generally due within 1 business day after scheduling. If it is scheduled at least 10 business days ahead, it is generally due within 3 business days.

Read the CMS guidance

I'm scheduling [procedure] and will be paying directly rather than using insurance. Under the federal No Surprises Act, I'd like a written Good Faith Estimate of the total expected charges, including facility and professional fees. Please include CPT codes.

2 · Provider records

Keep the receipt, payment proof, and provider confirmation.

Ask for an itemized receipt with CPT, NPI, and TIN. Keep proof of payment and written confirmation that a claim for the service will not be submitted to your health plan, the payment is accepted in full, and there will be no later balance bill.

3 · Your plan's procedure

Ask the plan for its process before paying.

Indiana requires the plan to have a credit procedure, identify its required documentation, and either publish its average discounted rates or point you to Indiana Health Prices.

Is my plan subject to Indiana Code 27-1-48.5, the out-of-pocket expense credit, and what documentation do you require for a direct payment to be credited toward my deductible and out-of-pocket maximum?

4 · Standard submission record

One-page checklist

Member name and plan or member ID
Provider name, NPI, and TIN
Service description and CPT code
Date of service
Amount paid and proof of payment
Good Faith Estimate, if obtained
Statement that a claim for the service was not and will not be submitted to the health plan
Date and member signature

After the plan responds

Tell us what happened, without personal details.

Share only the state, carrier, plan type, service category, dates, and status. Do not send documents, names, member IDs, diagnoses, or medical details.

Open outcome email

State: Indiana
Carrier:
Plan type:
Service category:
Date submitted:
Status: credited / denied / no response / still waiting

No personal details. No documents.