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IC 12-15-13-0.4
"Office" defined
Sec. 0.4. As used in this chapter, "office" includes the following:
(1) The office of Medicaid policy and planning.
(2) A managed care organization that has contracted with the
office of Medicaid policy and planning under this article.
(3) A person that has contracted with a managed care
organization described in subdivision (2).
As added by P.L.117-2008, SEC.2.
IC 12-15-13-0.5
"Clean claim" defined
Sec. 0.5. (a) Except as provided in section 0.6 of this chapter, as
used in this chapter, "clean claim" means a claim submitted by a
provider for payment under the Medicaid program that can be
processed without obtaining additional information from:
(1) the provider of the service; or
(2) a third party.
(b) The definition under subsection (a):
(1) includes a claim with errors originating in the state's claims
processing system; and
(2) does not include a claim:
(A) from a provider who is under investigation for fraud or
abuse (as used in 42 CFR 447.45(b); or
(B) under review for medical necessity.
As added by P.L.107-1996, SEC.2 and P.L.257-1996, SEC.2.
IC 12-15-13-0.6
"Clean claim" defined for purposes of IC 12-15-14
Sec. 0.6. (a) "Clean claim", as the term applies to payments to
nursing facilities under IC 12-15-14, means a claim submitted by a
provider for payment that meets the following conditions:
(1) Contains the following locators:
(A) Type of bill.
(B) Coverage dates.
(C) Bill status.
IC 12-15-13-0.7
Addition, deletion, or modification of locators
Sec. 0.7. The office may adopt rules under IC 4-22-2 that add,
delete, or modify the locators contained in section 0.6(a)(1) of this
chapter as necessary to conform with:
(1) changes in federal law or regulation; or
(2) directives from the United States Centers for Medicare and
Medicaid Services.
As added by P.L.107-1996, SEC.4 and P.L.257-1996, SEC.4.
Amended by P.L.66-2002, SEC.3.
IC 12-15-13-1.5
Payment of interest on claims submitted by nursing facilities
Sec. 1.5. (a) This section applies only to claims submitted for
payment by nursing facilities.
(b) If the office:
(1) fails to pay a clean claim in the time required under section
1(b) of this chapter; or
(2) denies or suspends a claim that is subsequently determined
to have been a clean claim when the claim was filed;
the office shall pay the provider interest on the Medicaid allowable
amount of the claim.
(c) Interest paid under subsection (b):
(1) accrues beginning:
(A) twenty-two (22) days after the date the claim is filed
under section 1(b)(1) of this chapter; or
(B) thirty-one (31) days after the date the claim is filed under
section 1(b)(2) of this chapter; and
(2) stops accruing on the date the office pays the claim.
(d) The office shall pay interest under subsection (b) at the same
rate as determined under IC 12-15-21-3(7)(A).
As added by P.L.107-1996, SEC.6 and P.L.257-1996, SEC.6.
Amended by P.L.42-2011, SEC.29.
IC 12-15-13-1.6
Payment, denial, or suspension of claims; notice of suspension or
denial
Sec. 1.6. (a) This section does not apply to claims submitted for
payment by nursing facilities.
(b) The office shall pay or deny each clean claim in accordance
with section 1.7 of this chapter.
(c) The office shall deny or suspend each claim that is not a clean
claim in accordance with subsection (d).
(d) The office shall deny or suspend each claim that is:
(1) not a clean claim; and
(2) submitted by a provider for payment under the Medicaid
program;
not more than thirty (30) days after the date the claim is received by
the office or, if IC 12-15-30 applies, by the contractor under
IC 12-15-30.
(e) If the office denies a provider's claim for payment under
subsection (d) or section 1.7 of this chapter, the office shall notify
the provider of each reason the claim was denied.
(f) If the office suspends a provider's claim for payment under
subsection (d), the office shall notify the provider of each reason the
claim was suspended.
As added by P.L.107-1996, SEC.7 and P.L.257-1996, SEC.7.
IC 12-15-13-1.7
Timing of payment or denial of claims; payment of interest
Sec. 1.7. (a) This section does not apply to claims submitted for
payment by nursing facilities.
(b) The office shall pay or deny each clean claim as follows:
(1) If the claim is filed electronically, within twenty-one (21)
days after the date the claim is received by:
(A) the office; or
(B) a contractor of the office under IC 12-15-30, if
IC 12-15-30 applies.
(2) If the claim is filed on paper, within thirty (30) days after
the date the claim is received by:
(A) the office; or
(B) a contractor of the office under IC 12-15-30, if
IC 12-15-30 applies.
(c) If:
(1) the office fails to pay or deny a clean claim in the time
required under subsection (b); and
(2) the office or a contractor of the office under IC 12-15-30
subsequently pays the claim;
the office shall pay the provider that submitted the claim interest on
the Medicaid allowable amount of the claim paid under this section.
(d) Interest paid under subsection (c) shall:
(1) begin accruing:
(A) twenty-two (22) days after the date the claim is filed
under subsection (b)(1); or
(B) thirty-one (31) days after the date the claim is filed under
subsection (b)(2); and
(2) stop accruing on the date the claim is paid.
(e) In paying interest under subsection (c), the office shall use the
same interest rate as provided in IC 12-15-21-3(7)(A).
As added by P.L.107-1996, SEC.8 and P.L.257-1996, SEC.8.
IC 12-15-13-2
Payments to providers; requirements; federal law or regulations
specifying reimbursement criteria
Sec. 2. (a) Except as provided in IC 12-15-14 and IC 12-15-15,
payments to Medicaid providers must be:
(1) consistent with efficiency, economy, and quality of care;
and
(2) sufficient to enlist enough providers so that care and
services are available under Medicaid, at least to the extent that
such care and services are available to the general population in
the geographic area.
(b) If federal law or regulations specify reimbursement criteria,
payment shall be made in compliance with those criteria.
As added by P.L.2-1992, SEC.9. Amended by P.L.278-1993(ss),
SEC.27.
IC 12-15-13-3
Repealed
(Repealed by P.L.229-2011, SEC.270.)
IC 12-15-13-3.5
Recovery of overpayment to noninstitutional provider; appeal
Sec. 3.5. (a) As used in this section, "noninstitutional provider"
means any Medicaid provider other than the following:
(1) A health facility licensed under IC 16-28.
(2) An ICF/MR (as defined in IC 16-29-4-2).
(b) If the office of the secretary or the office of the secretary's
designee believes that an overpayment to a noninstitutional provider
has occurred, the office of the secretary or the office of the
secretary's designee may submit to the noninstitutional provider a
preliminary review of draft audit findings.
(c) A noninstitutional provider that receives a preliminary review
of draft audit findings under subsection (b) may request
administrative reconsideration of the preliminary review of draft
audit findings not later than forty-five (45) days after the issuance of
the preliminary review of draft audit findings. The noninstitutional
provider may submit comments along with the request for
administrative reconsideration. The noninstitutional provider must
request administrative reconsideration before filing an appeal.
(d) Following administrative reconsideration of the preliminary
review of draft audit findings and any comments submitted along
with the noninstitutional provider's request for administrative
consideration and if the office of the secretary or the office of the
secretary's designee believes that an overpayment has occurred, the
office of the secretary or the office of the secretary's designee shall
notify the noninstitutional provider in writing that the office of the
secretary or the office of the secretary's designee:
IC 12-15-13-4
Recovery of overpayment to institutional provider; appeal
Sec. 4. (a) As used in this section, "institutional provider" means
the following:
(1) A health facility that is licensed under IC 16-28.
(2) An ICF/MR (as defined in IC 16-29-4-2).
(b) If the office of the secretary or the office of the secretary's
designee believes that an overpayment to an institutional provider
has occurred, the office of the secretary or the office of the
secretary's designee may do the following:
(1) Submit to the institutional provider a draft of the audit
findings and accept comments from the institutional provider
for consideration by the office of the secretary or the office of
the secretary's designee before the audit findings are finalized.
(2) Finalize the audit findings and issue the preliminary
recalculated Medicaid rate.
(c) An institutional provider that receives a preliminary
recalculated Medicaid rate under subsection (b)(2) may request
administrative reconsideration of the preliminary recalculated
Medicaid rate not later than forty-five (45) days after the issuance of
the preliminary recalculated rate. The institutional provider must
request administrative reconsideration before filing an appeal.
(d) Following reconsideration of an institutional provider's
comments, and if the office of the secretary or the office of the
secretary's designee believes that an overpayment has occurred, the
office of the secretary or the office of the secretary's designee shall
notify the institutional provider in writing that the office of the
secretary or the office of the secretary's designee:
(1) believes that the overpayment has occurred; and
(2) is issuing a final recalculated Medicaid rate.
(e) Upon the next payment cycle, the office of the secretary or the
office of the secretary's designee shall retroactively implement the
final recalculated Medicaid rate.
(f) If the institutional provider is dissatisfied with the
reconsideration response issued by the office of the secretary or the
office of the secretary's designee, the institutional provider may
request a hearing by filing an appeal with the office of the secretary
not later than sixty (60) days after the issuance of the reconsideration
response.
(g) If an institutional provider requests a hearing under subsection
(f) and the office of the secretary or the office of the secretary's
designee determines after the hearing and any subsequent appeal that
the institutional provider does not owe the money that the office of
the secretary or the office of the secretary's designee believed the
institutional provider owed, the office of the secretary or the office
of the secretary's designee shall repay the following to the
institutional provider not later than thirty (30) days after the
completion of the hearing:
(1) The amount of the alleged overpayment.
(2) Any interest paid by the institutional provider.
(3) Interest on the money described in subdivisions (1) and (2)
from the date of the institutional provider's repayment.
(h) Interest due under this section by either the institutional
provider or the office of the secretary shall be paid at a rate that is
determined by the commissioner of the department of state revenue
under IC 6-8.1-10-1(c) at the rate set by the commissioner for interest
payments from the department of state revenue to a taxpayer.
(i) Interest on an overpayment to an institutional provider is not
due from the institutional provider if the office of the secretary or the
office of the secretary's designee determines that the overpayment is
the result of an error by the following:
(1) The office of the secretary.
(2) A contractor of the office of the secretary.
(j) If interest on an overpayment to an institutional provider is due
from the institutional provider, the office of the secretary or the
office of the secretary's designee may, in the course of negotiations
with the institutional provider concerning an appeal filed under this
section, reduce the amount of interest due from the institutional
provider.
As added by P.L.229-2011, SEC.126.
IC 12-15-13-6
Notices or bulletins; timing; noncompliance
Sec. 6. (a) Except as provided by IC 12-15-35-50, a notice or
bulletin that is issued by:
(1) the office;
(2) a contractor of the office; or
(3) a managed care plan under the office;
concerning a change to the Medicaid program, including a change to
prior authorization, claims processing, payment rates, and medical
policies, that does not require use of the rulemaking process under
IC 4-22-2 may not become effective until thirty (30) days after the
date the notice or bulletin is communicated to the parties affected by
the notice or bulletin.
(b) The office must provide a written notice or bulletin described
in subsection (a) within five (5) business days after the date on the
notice or bulletin.
(c) If the office, a contractor of the office, or a managed care plan
under the office does not comply with the requirements in
subsections (a) and (b):
(1) the notice or bulletin is void;
(2) a claim may not be denied because the claim does not
comply with the void notice or bulletin; and
(3) the office, a contractor of the office, or a managed care plan
under the office may not reissue the bulletin or notice for thirty
(30) days unless the change is required by the federal
government to be implemented earlier.
IC 12-15-13-7.2
Use of diagnostic or procedure codes
Sec. 7.2. (a) As used in this section, "provider" has the meaning
set forth in IC 27-8-11-1.
(b) Not more than ninety (90) days after the effective date of a
diagnostic or procedure code described in this subsection:
(1) the office shall for all purposes begin using the most current
version of the:
(A) current procedural terminology (CPT);
(B) international classification of diseases (ICD);
(C) American Psychiatric Association's Diagnostic and
Statistical Manual of Mental Disorders (DSM);
(D) current dental terminology (CDT);
(E) Healthcare common procedure coding system (HCPCS);
and
(F) third party administrator (TPA);
codes under which the office processes claims for services
provided under the Medicaid program; and
(2) a provider shall begin using the most current version of the:
(A) current procedural terminology (CPT);
(B) international classification of diseases (ICD);
(C) American Psychiatric Association's Diagnostic and
Statistical Manual of Mental Disorders (DSM);
(D) current dental terminology (CDT);
(E) Healthcare common procedure coding system (HCPCS);
and
(F) third party administrator (TPA);
codes under which the provider submits claims for payment for
services provided under the Medicaid program.
(c) If a provider provides services that are covered under the
Medicaid program:
(1) after the effective date of the most current version of a
diagnostic or procedure code described in subsection (b); and
(2) before the office begins using the most current version of
the diagnostic or procedure code;
the office shall reimburse the provider under the version of the
diagnostic or procedure code that was in effect on the date that the
services were provided.
As added by P.L.161-2001, SEC.2. Amended by P.L.66-2002, SEC.4;
P.L.27-2011, SEC.3.