§ 12-15-21-3 — Required rules

Indiana § 12-15-21-3

• Jurisdiction: Indiana
• Art. 15: MEDICAID
• Ch. 21: Rules

Text

The rules adopted under section 2 of this
chapter must include the following:
(1) Providing for prior review and approval of medical services.
(2) Specifying the method of determining the amount of
reimbursement for services.
(3) Establishing limitations that are consistent with medical
necessity concerning the amount, scope, and duration of the
services and supplies to be provided. The rules may contain
limitations on services that are more restrictive than allowed
under a provider's scope of practice (as defined in Indiana law).
(4) Denying payment or instructing the contractor under IC 12-15-30 to deny payment to a provider for services provided to
an individual or claimed to be provided to an individual if the
office after investigation finds any of the following:
(A) The services claimed cannot be documented by the
provider.
(B) The claims were made for services or materials determined
by licensed medical staff of the office as not medically
reasonable and necessary.
(C) The amount claimed for the services has been or can be
paid from other sources.
(D) The services claimed were provided to a person other than
the person in whose name the claim is made.
(E) The services claimed were provided to a person who was
not eligible for Medicaid.
(F) The claim rises out of an act or practice prohibited by law
or by rules of the secretary.
(5) Recovering payment or instructing the contractor under IC 12-15-30-3 to recover payment from a provider for services
rendered to an individual or claimed to be rendered to an
individual if the office after investigation finds any of the
following:
(A) The services paid for cannot be documented by the
provider.
(B) The amount paid for such services has been or can be paid
from other sources.
(C) The services were provided to a person other than the
person in whose name the claim was made and paid.
(D) The services paid for were provided to a person who was
not eligible for Medicaid.
(E) The paid claim rises out of an act or practice prohibited by
law or by rules of the secretary.
(6) Recovering interest due from a provider:
(A) at a rate that is the percentage rounded to the nearest whole
number that equals the average investment yield on state
general fund money for the state's previous fiscal year,
excluding pension fund investments, as published in the state
comptroller's comprehensive annual financial report; and
(B) accruing from the date of overpayment;
on amounts paid to the provider that are in excess of the amount
subsequently determined to be due the provider as a result of an
audit, a reimbursement cost settlement, or a judicial or an
administrative proceeding.
(7) Paying interest to providers:
(A) at a rate that is the percentage rounded to the nearest whole
number that equals the average investment yield on state
general fund money for the state's previous fiscal year,
excluding pension fund investments, as published in the state
comptroller's comprehensive annual financial report; and
(B) accruing from the date that an overpayment is erroneously
recovered by the office until the office restores the overpayment
to the provider.
(8) Establishing a system with the following conditions:
(A) Audits may be conducted by the office after service has
been provided and before reimbursement for the service has
been made.
(B) Reimbursement for services may be denied if an audit
conducted under clause (A) concludes that reimbursement
should be denied.
(C) Audits may be conducted by the office after service has
been provided and after reimbursement has been made.
(D) Reimbursement for services may be recovered if an audit
conducted under clause (C) concludes that the money
reimbursed should be recovered.
[Pre-1992 Revision Citation: 12-1-7-15.7(b) part.]

Legislative History

As added by P.L.2-1992, SEC.9. Amended by P.L.278-1993(ss), SEC.28; P.L.42-1995, SEC.23; P.L.107-1996, SEC.10; P.L.8-2005, SEC.2; P.L.113-2014, SEC.35; P.L.9-2024, SEC.332.