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Claim Administrative Review and Appeal

If a provider disagrees with the Indiana Health Coverage Programs (IHCP) determination of payment, the provider's right of recourse is to file an administrative review and appeal, as provided for in Indiana Administrative Code 405 IAC 1-1-3.

Requests for administrative review must be filed with the entity that processed the claim, as described below. See the IHCP Quick Reference Guide for contact information.

Fee-for-Service Claims

Pharmacy claims reimbursed under the fee-for-service (FFS) delivery system are the responsibility of OptumRx. Contact the OptumRx helpdesk for information regarding administrative review and appeal of these claims.

For nonemergency medical transportation (NEMT) claims adjudicated by the FFS transportation broker, Southeastrans, providers must submit administrative review requests via email to INClaims@southeastrans.com. If the administrative review process does not resolve the issue, providers may submit a formal claim appeal with Southeastrans by mail.

For all other claims reimbursed under the FFS delivery system, administrative reviews are the responsibility of the IHCP fiscal agent, Gainwell Technologies (formerly DXC Technology).

Requests for an administrative review of a claim determination made by Gainwell should be submitted via one of the following methods:

  • Secure correspondence on the IHCP Provider Healthcare Portal (message category: Claim Administrative Review Request)
  • By mail using the Indiana Health Coverage Programs Administrative Review Request form
  • By mail as a letter on the provider's letterhead, with Administrative Review clearly noted on the face of the letter

The request should include the relevant claim numbers (Claim IDs) and should clearly state the reason for the disagreement with the denial or the reimbursement amount. The following attachments must be included with the request:

  • A properly completed claim form
  • All required claim attachments
  • A copy of the original claim and related Remittance Advice (RA) statements
  • Any additional documentation supporting reconsideration

If the administrative review response is unfavorable to the provider, the provider may file an appeal with the Indiana Family and Social Services Administration (FSSA). For more information about this administrative review and appeals process, see the Claim Administrative Review and Appeals provider reference module.

Managed Care Claims

Administrative reviews related to claims for members enrolled in Hoosier Healthwise, Hoosier Care Connect, or Healthy Indiana Plan (HIP) are the responsibility of the managed care entity (MCE) with which the member was enrolled at the time of service. The exception is for services carved out of managed care and processed under the FFS delivery system. Administrative reviews related to claims for carved-out services follow the FFS administrative review guidelines.

Each MCE that participates in an IHCP managed care program is required to have a formal procedure for providers requesting reconsideration of claim determinations made by the MCE. For specific information related to the MCE process, contact the MCE directly.

 

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