§ 12-15-29-4.5 — Insurer's acceptance and response to Medicaid claim; prior authorization

Indiana § 12-15-29-4.5

• Jurisdiction: Indiana
• Art. 15: MEDICAID
• Ch. 29: Insurance

Text

5. (a) An insurer shall:
(1) accept a Medicaid claim for a Medicaid recipient for three (3)
years from the date the service was provided; and
(2) respond to an inquiry by the office regarding the claim not
later than sixty (60) days after receiving the inquiry.
(b) An insurer may not deny a Medicaid claim submitted by the
office solely on the basis of:
(1) the date of submission of the claim;
(2) the type or format of the claim form;
(3) the method of submission of the claim; or
(4) a failure to provide proper documentation at the point of sale
that is the basis of the claim;
if the claim is submitted by the office within three (3) years from the
date the service was provided as required in subsection (a) and the
office commences action to enforce the office's rights regarding the
claim within six (6) years of the office's submission of the claim.
(c) In accordance with 42 U.S.C. 1396a, an insurer, other than
Medicare, Medicare Advantage, and Medicare Part D, may not deny a
Medicaid claim submitted by the office solely due to a lack of prior
authorization. An insurer shall:
(1) after December 31, 2020, meet the requirements set forth in
IC 27-1-37.5;
(2) conduct the prior authorization on a retrospective basis for
claims where prior authorization is necessary; and
(3) adjudicate any claim authorized in this manner as if the claim
received prior authorization.

Legislative History

As added by P.L.187-2007, SEC.5. Amended by P.L.265-2019, SEC.2; P.L.26-2025, SEC.3.