reglab/statecodes huggingface dataset:
2023 Indiana Code › Title 12. Human Services › Article 15. Medicaid › Chapter 11. Provider Agreements and Competitive Bidding › 12-15-11-3. Provider Agreement Requirements

Sec. 3. A provider agreement must do the following:
(1) Include information that the office determines necessary to facilitate carrying out of IC 12-15.
(2) Prohibit the provider from requiring payment from a recipient of Medicaid, except where a copayment is required by law.
(3) For providers categorized as high risk to the Medicaid program under 42 U.S.C. 1395cc(j)(2)(B) and 42 CFR 455.450, require the submission of necessary information, forms, or consents for the office to obtain a national criminal history background check or, as allowed by the office, a fingerprint-based criminal history check, through a contractor under IC 12-15-30 or the state police department under IC 10-13-3-39 of any person who:
(A) holds at least a five percent (5%) ownership interest in a facility or entity; or
(B) is a member of the board of directors of a nonprofit facility or entity;
in which the provider applicant plans to provide Medicaid services under the provider agreement. The provider applicant is responsible for the cost of the national criminal history background check or fingerprint-based criminal history check.
[Pre-1992 Revision Citation: 12-1-7-15.1(b) part.]
As added by P.L.2-1992, SEC.9. Amended by P.L.197-2013, SEC.12; P.L.35-2016, SEC.38.
2023 Indiana Code › Title 12. Human Services › Article 15. Medicaid › Chapter 11. Provider Agreements and Competitive Bidding › 12-15-11-4. Provider Agreement to Provide Physician Services; Site Visit for Moderate or High Categorical Risk Designees

Sec. 4. (a) A provider desiring to participate in the Medicaid program by providing physician services as a managed care provider must enter into a provider agreement with the office or the contractor under IC 12-15-30 to provide Medicaid services.
(b) Before the office may approve a provider agreement, the office shall conduct a pre-enrollment site visit for provider applicants that are designated as moderate or high categorical risks to the Medicaid program under 42 U.S.C. 1395cc(j)(2)(B) and 42 CFR 455.450.
[Pre-1992 Revision Citation: 12-1-7-15.1(c).]
As added by P.L.2-1992, SEC.9. Amended by P.L.197-2013, SEC.13.
2023 Indiana Code › Title 12. Human Services › Article 15. Medicaid › Chapter 11. Provider Agreements and Competitive Bidding › 12-15-11-5. Compliance With Enrollment Requirements

Sec. 5. A provider who participates in the Medicaid program must comply with the enrollment requirements that are established under rules adopted under IC 4-22-2 by the secretary.
[Pre-1992 Revision Citation: 12-1-7-15.1(d).]
As added by P.L.2-1992, SEC.9. Amended by P.L.195-2018, SEC.4; P.L.190-2023, SEC.2.
2023 Indiana Code › Title 12. Human Services › Article 15. Medicaid › Chapter 11. Provider Agreements and Competitive Bidding › 12-15-11-6. Prohibition on Exclusion of Medicaid Provider From Participation in Medicaid and Other Networks

Sec. 6. (a) After a provider signs a provider agreement under this chapter, the office may not exclude the provider from participating in the Medicaid program by entering into an exclusive contract with another provider or group of providers, except as provided under section 7 of this chapter.
(b) The office or a managed care organization contracting with the office may not prohibit a provider from participating in a network of another insurer, managed care organization, or health maintenance organization.
[Pre-1992 Revision Citation: 12-1-7-15.1(e).]
As added by P.L.2-1992, SEC.9. Amended by P.L.93-2020, SEC.1.
2023 Indiana Code › Title 12. Human Services › Article 15. Medicaid › Chapter 11. Provider Agreements and Competitive Bidding › 12-15-11-7. Competitive Bids; Services and Items for Which Bids May Be Sought

Sec. 7. The office may seek competitive bids for the following items or services provided under Medicaid:
(1) Prescribed drugs and services for state operated institutions.
(2) Physical therapy and other therapeutic services.
(3) Prescribed laboratory and x-ray services.
(4) Eyeglasses and prosthetic devices.
(5) Medical equipment and supplies.
(6) Transportation services.
[Pre-1992 Revision Citation: 12-1-7-15.1(f).]
As added by P.L.2-1992, SEC.9.
2023 Indiana Code › Title 12. Human Services › Article 15. Medicaid › Chapter 11. Provider Agreements and Competitive Bidding › 12-15-11-8. Use of Provider Identification Number; Prohibition on Limiting Claims for Primary Care Services

Sec. 8. (a) A community mental health center may use the center's provider identification number to file any Medicaid claim, including primary care health services, if the community mental health center:
(1) is otherwise treating the individual for a mental health condition or an addictive disorder; and
(2) meets the requirements to provide the services rendered.
(b) The office may not require a community mental health center to obtain a separate provider identification number to provide services that the community mental health center meets the requirements to provide.
(c) The office may not limit the filing of a Medicaid claim by a community mental health center for primary care services, mental health conditions, and addictive disorders on the same day as long as the claim is filed in accordance with the rules set forth by the office and the services are covered services and necessary to ensure coordinated care for the recipient.
As added by P.L.185-2015, SEC.12.
2023 Indiana Code › Title 12. Human Services › Article 15. Medicaid › Chapter 11. Provider Agreements and Competitive Bidding › 12-15-11-9. Implementation of Centralized Credentials Verification Organization; Requirements; Prohibition on Requiring Additional Credentialing; Managed Care Organizations; Administrative Review; Rules

Note: This version of section effective until 1-1-2024. See also following version of this section, effective 1-1-2024.
Sec. 9. (a) The office shall implement a centralized credentials verification organization and credentialing process that:
(1) uses a common application, as determined by provider type;
(2) issues a single credentialing decision applicable to all Medicaid programs, except as determined by the office;
(3) recredentials and revalidates provider information not less than once every three (3) years;
(4) requires attestation of enrollment and credentialing information every six (6) months; and
(5) is certificated or accredited by the National Committee for Quality Assurance or its successor organization.
(b) A managed care organization or contractor of the office may not require additional credentialing requirements in order to participate in a managed care organization's network. However, a contractor may collect additional information from the provider in order to complete a contract or provider agreement.
(c) A managed care organization or contractor of the office is not required to contract with a provider.
(d) A managed care organization or contractor of the office shall:
(1) send representatives to meetings and participate in the credentialing process as determined by the office; and
(2) not require additional credentialing information from a provider if a non-network credentialed provider is used.
(e) Except when a provider is no longer enrolled with the office, a credential acquired under this chapter is valid until recredentialing is required.
(f) An adverse action under this section is subject to IC 4-21.5.
(g) The office may adopt rules under IC 4-22-2 to implement this section.
As added by P.L.195-2018, SEC.5. Amended by P.L.32-2021, SEC.31.
2023 Indiana Code › Title 12. Human Services › Article 15. Medicaid › Chapter 11. Provider Agreements and Competitive Bidding › 12-15-11-10. Prohibition on Requiring a Telehealth Provider to Have an Indiana Address, Site, or In-State Service Address

Effective 1-1-2024.
Sec. 10. The office may not require the following:
(1) A provider that is licensed, certified, registered, or authorized with the appropriate state agency or board and exclusively offers telehealth services (as defined in IC 12-15-5-11(a)) to maintain a physical address or site in Indiana to be eligible for enrollment as a Medicaid provider.
(2) A telehealth provider group with providers that are licensed, certified, registered, or authorized with the appropriate state agency or board to have an in-state service address to be eligible to enroll as a Medicaid vendor or Medicaid provider group.
As added by P.L.229-2023, SEC.1.
2023 Indiana Code › Title 12. Human Services › Article 15. Medicaid › Chapter 11.5. Lake County Disproportionate Share Hospitals › 12-15-11.5-0.5. Nonapplicability to Certain Managed Care Organizations

Sec. 0.5. This chapter does not apply to a managed care organization that, on or before July 1, 2000, did not directly contract with a hospital (as defined in section 1 of this chapter) for the provision of services under the office's managed care program.
As added by P.L.141-2001, SEC.1. Amended by P.L.152-2017, SEC.7.
2023 Indiana Code › Title 12. Human Services › Article 15. Medicaid › Chapter 11.5. Lake County Disproportionate Share Hospitals › 12-15-11.5-1. "Hospital"

Sec. 1. As used in this chapter, "hospital" refers to an acute care hospital provider that:
(1) is licensed under IC 16-21;
(2) qualifies as a disproportionate share hospital under IC 12-15-16; and
(3) is the sole disproportionate share hospital in a city located in a county having a population of more than four hundred thousand (400,000) and less than seven hundred thousand (700,000).
As added by P.L.142-2000, SEC.2. Amended by P.L.11-2023, SEC.42.
2023 Indiana Code › Title 12. Human Services › Article 15. Medicaid › Chapter 11.5. Lake County Disproportionate Share Hospitals › 12-15-11.5-2. Hospital as Contracted Provider to Eligible Individuals

Sec. 2. The office's managed care organization shall regard a hospital as a contracted provider in the office's managed care program, which provides a capitated prepayment managed care system, for the provision of medical services to each individual who:
(1) is eligible to receive services under IC 12-15 and has enrolled in the office's managed care services program;
(2) resides in the same city in which the hospital is located; and
(3) has selected a primary care provider who:
(A) is a contracted provider with the office's managed care organization; and
(B) has medical staff privileges at the hospital.
As added by P.L.142-2000, SEC.2. Amended by P.L.141-2001, SEC.2; P.L.152-2017, SEC.8.
2023 Indiana Code › Title 12. Human Services › Article 15. Medicaid › Chapter 11.5. Lake County Disproportionate Share Hospitals › 12-15-11.5-3. Repealed

As added by P.L.142-2000, SEC.2. Amended by P.L.141-2001, SEC.3; P.L.122-2002, SEC.1. Repealed by P.L.145-2005, SEC.30.
2023 Indiana Code › Title 12. Human Services › Article 15. Medicaid › Chapter 11.5. Lake County Disproportionate Share Hospitals › 12-15-11.5-4.1. Repealed

As added by P.L.141-2001, SEC.4. Amended by P.L.122-2002, SEC.2. Repealed by P.L.145-2005, SEC.30.
2023 Indiana Code › Title 12. Human Services › Article 15. Medicaid › Chapter 11.5. Lake County Disproportionate Share Hospitals › 12-15-11.5-6. Claim for Reimbursement Treated as Disputed Claim

Sec. 6. A claim for reimbursement for services shall be treated as a disputed claim under this chapter if:
(1) it is submitted within one hundred twenty (120) days after the date that services are rendered;
(2) it is denied by the managed care organization;
(3) the hospital submits a written notice of dispute for the claim to the managed care organization not more than sixty (60) days after the receipt of the denial notice;
(4) it is appealed in accordance with the managed care organization's internal appeals process; and
(5) payment for the claim is denied by the managed care organization following its internal appeals process.
As added by P.L.142-2000, SEC.2. Amended by P.L.152-2017, SEC.9.
2023 Indiana Code › Title 12. Human Services › Article 15. Medicaid › Chapter 11.5. Lake County Disproportionate Share Hospitals › 12-15-11.5-7. Conclusion of Appeal

Sec. 7. The office's managed care organization must conclude an appeal under section 6(4) of this chapter and notify the hospital of its decision not more than thirty-five (35) days after the managed care organization receives a notice from the hospital disputing the managed care organization's denial of a claim.
As added by P.L.142-2000, SEC.2. Amended by P.L.152-2017, SEC.10.
2023 Indiana Code › Title 12. Human Services › Article 15. Medicaid › Chapter 11.5. Lake County Disproportionate Share Hospitals › 12-15-11.5-8. Dispute Resolution Procedure Requirements

Sec. 8. (a) A contract entered into by a hospital with the office's managed care organization for the provision of services under the office's managed care program must include a dispute resolution procedure for all disputed claims. Unless agreed to in writing by the hospital and the office's managed care organization, the dispute resolution procedure must include the following requirements:
(1) That submission of disputed claims must be made to an independent arbitrator selected under subsection (b).
(2) Each claim must set forth with specificity the issues to be arbitrated, the amount involved, and the relief sought.
(3) That the hospital and the office's managed care organization shall attempt in good faith to resolve all disputed claims.
(4) The hospital shall submit to the arbitrator any claims that remain in dispute sixty (60) calendar days after the hospital receives written notice as provided under section 7 of this chapter.
(5) That resolution of disputes by the arbitrator must occur not later than ninety (90) calendar days after submission of disputed claims to the arbitrator, unless the parties mutually agree otherwise.
(6) That determinations of the arbitrator are final and binding and not subject to any appeal or review procedure.
(7) That the arbitrator does not have the authority to award any punitive or exemplary damages or to vary or ignore the terms of any contract between the parties and shall be bound by controlling law.
(8) That judgment upon the award rendered by the arbitrator may be entered and enforced in and is subject to the jurisdiction of a court with jurisdiction in Indiana.
(9) That the cost of the arbitrator must be shared equally by the parties, and each party must bear its own attorney and witness fees.
(b) The parties to a contract described in subsection (a) shall mutually agree on an independent arbitrator, or, if the parties are unable to reach agreement on an independent arbitrator, the following procedure must be followed:
(1) Each party shall select an independent representative, and the independent representatives shall select a panel of three (3) independent arbitrators who have experience in institutional and professional health care delivery practices and procedures and have had no prior dealing with either party other than as an arbitrator.
(2) The parties will each strike one (1) arbitrator from the panel selected under subdivision (1), and the remaining arbitrator serves as the arbitrator of the disputed claims under subsection (a).
(3) The procedures for selecting an arbitrator under this section must be completed not later than twenty (20) calendar days after the hospital provides written notice of at least one (1) disputed claim.
As added by P.L.142-2000, SEC.2. Amended by P.L.152-2017, SEC.11.
2023 Indiana Code › Title 12. Human Services › Article 15. Medicaid › Chapter 11.5. Lake County Disproportionate Share Hospitals › 12-15-11.5-9. Arbitration Process for Dispute Resolution Between Hospital and Managed Care Organization

Sec. 9. The arbitration process described in section 8 of this chapter shall also be followed for resolution of disputed claims between a hospital and the office's managed care organization, if the hospital is not a contracted provider in the office's managed health care program.
As added by P.L.142-2000, SEC.2. Amended by P.L.152-2017, SEC.12.
2023 Indiana Code › Title 12. Human Services › Article 15. Medicaid › Chapter 11.5. Lake County Disproportionate Share Hospitals › 12-15-11.5-10. Arbitration of Disputed Claims

Sec. 10. A hospital and the managed care organization of the office shall use the arbitration procedure in section 8 of this chapter for the resolution of all disputed claims that have accrued as of March 17, 2000.
As added by P.L.220-2011, SEC.265. Amended by P.L.152-2017, SEC.13.
2023 Indiana Code › Title 12. Human Services › Article 15. Medicaid › Chapter 12. Managed Care › 12-15-12-0.3. "Emergency Medical Condition"

Sec. 0.3. As used in this chapter, "emergency medical condition" means a medical condition manifesting itself by acute symptoms, including severe pain, of sufficient severity that a prudent lay person with an average knowledge of health and medicine could reasonably expect the absence of immediate medical attention to result in:
(1) serious jeopardy to the health of:
(A) the individual; or
(B) in the case of a pregnant woman, the woman or her unborn child;
(2) serious impairment to bodily functions; or
(3) serious dysfunction of any bodily organ or part.
As added by P.L.223-2001, SEC.4.
2023 Indiana Code › Title 12. Human Services › Article 15. Medicaid › Chapter 12. Managed Care › 12-15-12-0.5. "Emergency Services"

Sec. 0.5. As used in this chapter, "emergency services" means covered inpatient and outpatient services that are:
(1) furnished by a provider qualified to furnish emergency services; and
(2) needed to evaluate or stabilize an emergency medical condition.
As added by P.L.223-2001, SEC.5.
2023 Indiana Code › Title 12. Human Services › Article 15. Medicaid › Chapter 12. Managed Care › 12-15-12-0.7. "Post-Stabilization Care Services"

Sec. 0.7. As used in this chapter, "post-stabilization care services" means covered services related to an emergency medical condition that are provided after an enrollee is stabilized in order to maintain the stabilized condition or, under the circumstances described in IC 12-15-12-17(b)(3), to improve or resolve the enrollee's condition.
As added by P.L.223-2001, SEC.6.
2023 Indiana Code › Title 12. Human Services › Article 15. Medicaid › Chapter 12. Managed Care › 12-15-12-0.9. Applicability; Medicaid Law Controlling Over Conflicting Insurance Law

Sec. 0.9. (a) This section applies only with respect to the responsibilities of a managed care organization under:
(1) this article;
(2) IC 12-17.6;
(3) 42 CFR 438; or
(4) a rule adopted under a law described in subdivision (1) or (2).
(b) Except as provided in IC 27-1-37.5 after December 31, 2020, if a provision of, or rule adopted under, IC 27 conflicts with the administration of the programs under a law described in subsection (a), the law described in subsection (a) is controlling.
As added by P.L.152-2017, SEC.14. Amended by P.L.265-2019, SEC.1.
2023 Indiana Code › Title 12. Human Services › Article 15. Medicaid › Chapter 12. Managed Care › 12-15-12-1. Providers From Whom Recipients May Obtain Services Other Than Physician Services; Exceptions

Sec. 1. Except as provided in sections 6, 7, and 8 of this chapter, a Medicaid recipient may obtain any Medicaid services, with the exception of physician services, from a provider who has entered into a provider agreement under IC 12-15-11.
[Pre-1992 Revision Citation: 12-1-7-16.1(b).]
As added by P.L.2-1992, SEC.9.
2023 Indiana Code › Title 12. Human Services › Article 15. Medicaid › Chapter 12. Managed Care › 12-15-12-2. Providers From Whom Recipients May Receive Physician Services; Exceptions

Sec. 2. Except as provided in sections 8 and 9 of this chapter, a Medicaid recipient may receive physician services from a managed care provider selected by the recipient from a list of managed care providers furnished the recipient by the office.
[Pre-1992 Revision Citation: 12-1-7-16.1(c) part.]
As added by P.L.2-1992, SEC.9.
2023 Indiana Code › Title 12. Human Services › Article 15. Medicaid › Chapter 12. Managed Care › 12-15-12-3. List of Managed Care Providers Furnished Recipient; Providers Included; Exception

Sec. 3. Except as provided in section 9 of this chapter, the list of managed care providers furnished the recipient must include the names of all managed care providers who meet the following requirements:
(1) Have entered into a provider agreement with the office under IC 12-15-11 to provide physician services to Medicaid recipients.
(2) Provide physician services in the geographic area in which the recipient resides.
[Pre-1992 Revision Citation: 12-1-7-16.1(c) part.]
As added by P.L.2-1992, SEC.9.
2023 Indiana Code › Title 12. Human Services › Article 15. Medicaid › Chapter 12. Managed Care › 12-15-12-4. Failure by Recipient to Select Managed Care Provider Within Reasonable Time; Assignment by Office; Exception

Sec. 4. Except as provided in section 9 of this chapter, if a recipient fails to select a managed care provider within a reasonable time after the list is furnished the recipient, the office may assign a managed care provider to the recipient.
[Pre-1992 Revision Citation: 12-1-7-16.1(c) part.]
As added by P.L.2-1992, SEC.9.
2023 Indiana Code › Title 12. Human Services › Article 15. Medicaid › Chapter 12. Managed Care › 12-15-12-4.5. Managed Care Prescription Drug Program Requirements

Sec. 4.5. A managed care provider's contract or provider agreement with the office may include a prescription drug program, subject to IC 12-15-5-5, IC 12-15-35, and IC 12-15-35.5.
As added by P.L.101-2005, SEC.2.
2023 Indiana Code › Title 12. Human Services › Article 15. Medicaid › Chapter 12. Managed Care › 12-15-12-5. Circumstances Permitting Recipient to Receive Physician Services From Provider Other Than Managed Care Provider; Exceptions

Sec. 5. Except as provided in sections 6 and 7 of this chapter, a Medicaid recipient may not receive physician services from a provider other than the managed care provider selected by the recipient under section 2 of this chapter, except as follows:
(1) In an emergency.
(2) Upon the written referral of the managed care provider.
(3) As provided in sections 6 through 9 of this chapter.
[Pre-1992 Revision Citation: 12-1-7-16.1(d).]
As added by P.L.2-1992, SEC.9.
2023 Indiana Code › Title 12. Human Services › Article 15. Medicaid › Chapter 12. Managed Care › 12-15-12-6. Admission to Hospital by Physician Other Than Managed Care Provider; Notification of Managed Care Provider; Services for Which Payment Made

Sec. 6. (a) A Medicaid recipient may be admitted to a hospital by a physician other than the recipient's managed care provider if the recipient requires immediate medical treatment.
(b) The admitting physician shall notify the recipient's managed care provider of the recipient's admission not more than forty-eight (48) hours after the recipient's admission.
(c) Payment for services provided a recipient admitted to a hospital under this section shall be made only for services that the office or the contractor under IC 12-15-30 determines were medically reasonable and necessary.
[Pre-1992 Revision Citation: 12-1-7-16.1(e).]
As added by P.L.2-1992, SEC.9.
2023 Indiana Code › Title 12. Human Services › Article 15. Medicaid › Chapter 12. Managed Care › 12-15-12-7. Providers From Whom Recipients May Obtain Eye Care Services Other Than Surgical Services

Sec. 7. A Medicaid recipient may obtain eye care services, except for surgical services, from any provider licensed under IC 25-22.5 or IC 25-24 who has entered into a provider agreement under IC 12-15-11.
[Pre-1992 Revision Citation: 12-1-7-16.1(f).]
As added by P.L.2-1992, SEC.9.
2023 Indiana Code › Title 12. Human Services › Article 15. Medicaid › Chapter 12. Managed Care › 12-15-12-8. Providers From Whom Recipients May Obtain Foot Care Services

Sec. 8. A Medicaid recipient may obtain foot care services from any provider licensed under IC 25-22.5 or IC 25-29 who has entered into a provider agreement under IC 12-15-11.
[Pre-1992 Revision Citation: 12-1-7-16.1(g).]
As added by P.L.2-1992, SEC.9.
2023 Indiana Code › Title 12. Human Services › Article 15. Medicaid › Chapter 12. Managed Care › 12-15-12-9. Providers From Whom Recipients May Obtain Psychiatric Services

Sec. 9. A Medicaid recipient may obtain psychiatric services from any provider licensed under IC 25-22.5 who has entered into a provider agreement under IC 12-15-11.
[Pre-1992 Revision Citation: 12-1-7-16.1(h).]
As added by P.L.2-1992, SEC.9.
2023 Indiana Code › Title 12. Human Services › Article 15. Medicaid › Chapter 12. Managed Care › 12-15-12-10. Selection or Assignment of Managed Care Provider; Selection of New Provider; Exception

Sec. 10. (a) A Medicaid recipient who has selected or been assigned a managed care provider under this chapter may not select a new managed care provider for twelve (12) months after the managed care provider was selected or assigned.
(b) The office may make an exception to the requirement under subsection (a) if the office determines that circumstances warrant a change.
[Pre-1992 Revision Citation: 12-1-7-16.1(i).]
As added by P.L.2-1992, SEC.9.
2023 Indiana Code › Title 12. Human Services › Article 15. Medicaid › Chapter 12. Managed Care › 12-15-12-11. Waiver From Department of Health and Human Services; Implementation of Chapter

Sec. 11. The office shall seek the necessary waiver under 42 U.S.C. 1396n(b)(1) from the United States Department of Health and Human Services to implement this chapter.
[Pre-1992 Revision Citation: 12-1-7-16.1(j).]
As added by P.L.2-1992, SEC.9.
2023 Indiana Code › Title 12. Human Services › Article 15. Medicaid › Chapter 12. Managed Care › 12-15-12-12. Payments to Providers

Sec. 12. For a managed care program or demonstration project established or authorized by the office, or established or authorized by another entity or agency working in conjunction with or under agreement with the office, the office must provide for payment to providers in the managed care program that the office finds is reasonable and adequate to meet the costs that must be incurred by efficiently and economically operated providers in order to:
(1) provide care and services in conformity with applicable state and federal laws, regulations, and quality and safety standards; and
(2) ensure that individuals eligible for medical assistance under the managed care program or demonstration project have reasonable access (taking into account geographic location and reasonable travel time) to the services provided by the managed care program.
As added by P.L.93-1995, SEC.3.
2023 Indiana Code › Title 12. Human Services › Article 15. Medicaid › Chapter 12. Managed Care › 12-15-12-13. Permitted Forms

Sec. 13. (a) The office and an entity with which the office contracts for the payment of claims shall accept claims submitted on any of the following forms by an individual or organization that is a contractor or subcontractor of the office:
(1) CMS-1500.
(2) CMS-1450 (UB-04).
(3) American Dental Association (ADA) claim form.
(4) Pharmacy and compound drug form.
(b) The office and an entity with which the office contracts for the payment of claims:
(1) may designate as acceptable claim forms other than a form listed in subsection (a); and
(2) may not mandate the use of a crossover claim form.
As added by P.L.256-2001, SEC.2. Amended by P.L.208-2018, SEC.3.
2023 Indiana Code › Title 12. Human Services › Article 15. Medicaid › Chapter 12. Managed Care › 12-15-12-14. Repealed

As added by P.L.291-2001, SEC.160. Amended by P.L.170-2002, SEC.81; P.L.107-2002, SEC.11; P.L.1-2003, SEC.55; P.L.119-2012, SEC.106. Repealed by P.L.145-2014, SEC.6.
2023 Indiana Code › Title 12. Human Services › Article 15. Medicaid › Chapter 12. Managed Care › 12-15-12-15. Coverage for Emergency Services

Sec. 15. A managed care organization shall:
(1) cover and pay for all medically necessary screening services provided to an individual who presents to an emergency department with an emergency medical condition; and
(2) beginning July 1, 2001, neither deny nor fail to process a claim for reimbursement for emergency services on the basis that the enrollee's primary care provider's authorization code for the services was not obtained before or after the services were rendered.
As added by P.L.223-2001, SEC.7. Amended by P.L.152-2017, SEC.15.
2023 Indiana Code › Title 12. Human Services › Article 15. Medicaid › Chapter 12. Managed Care › 12-15-12-18. Payment for Emergency Services

Sec. 18. (a) Except as provided in subsection (b), this section applies to:
(1) emergency services provided to an individual enrolled in a Medicaid risk based managed care program; and
(2) medically necessary screening services provided to an individual enrolled in a Medicaid risk based managed care program;
who presents to an emergency department with an emergency medical condition.
(b) This section does not apply to emergency services or screening services provided to an individual enrolled in a Medicaid risk based managed care program by a provider who has contracted with the individual's managed care organization to provide emergency services to the individual.
(c) Payment for emergency services and medically necessary screening services in the emergency department of a hospital licensed under IC 16-21 must be in an amount equal to one hundred percent (100%) of the current Medicaid fee for service reimbursement rates for such services.
(d) Payment under subsection (c) is the responsibility of the enrollee's managed care organization. This subsection does not prohibit the managed care organization from entering into a subcontract with another managed care organization providing for the latter managed care organization to assume financial responsibility for making the payments required under this section.
(e) This section does not limit the ability of the managed care organization to:
(1) review; and
(2) make a determination of;
the medical necessity of the services provided in a hospital's emergency department for purposes of determining coverage for such services.
As added by P.L.223-2001, SEC.9. Amended by P.L.152-2017, SEC.17.
2023 Indiana Code › Title 12. Human Services › Article 15. Medicaid › Chapter 12. Managed Care › 12-15-12-18.5. Reimbursement for Emergency Medical Services Provider Organizations; Implementation

Sec. 18.5. (a) Except as provided in subsection (b), this section applies to an emergency medical services provider organization that meets the following requirements:
(1) Is certified by the Indiana emergency medical services commission to provide emergency medical services.
(2) Is a Medicaid provider.
(b) This section does not apply to an emergency medical services provider organization that has contracted with the recipient's managed care organization to provide emergency medical services described in this section at a negotiated rate that is different than the Medicare rate described in this section.
(c) Beginning July 1, 2023, a managed care organization shall reimburse an emergency medical services provider organization for Medicaid covered services provided to a Medicaid recipient, including:
(1) advanced life support services;
(2) basic life support services; and
(3) nonemergency medical transportation services;
that are within the emergency medical services provider organization's scope of practice at a rate that is comparable to the federal Medicare reimbursement rate for the service provided by the emergency medical services provider organization. However, the reimbursement rate specified in this subsection may not be implemented by the office of the secretary before July 1, 2023.
As added by P.L.142-2022, SEC.2.
2023 Indiana Code › Title 12. Human Services › Article 15. Medicaid › Chapter 12. Managed Care › 12-15-12-19. Repealed

As added by P.L.291-2001, SEC.161. Amended by P.L.66-2002, SEC.2; P.L.212-2003, SEC.1; P.L.13-2004, SEC.1; P.L.48-2005, SEC.1; P.L.18-2007, SEC.1; P.L.205-2013, SEC.189; P.L.53-2014, SEC.104. Repealed by P.L.152-2017, SEC.18.
2023 Indiana Code › Title 12. Human Services › Article 15. Medicaid › Chapter 12. Managed Care › 12-15-12-20. Child Lead Poisoning Screening

Sec. 20. The office shall develop the following:
(1) A measure to evaluate the performance of a managed care organization in screening a child who is less than six (6) years of age for lead poisoning.
(2) A system to maintain the results of an evaluation under subdivision (1) in written form.
(3) A performance incentive program for managed care organizations evaluated under subdivision (1).
As added by P.L.135-2005, SEC.1. Amended by P.L.152-2017, SEC.19.
2023 Indiana Code › Title 12. Human Services › Article 15. Medicaid › Chapter 12. Managed Care › 12-15-12-21. Accreditation

Sec. 21. (a) Not later than January 1, 2011, the following must be accredited by the National Committee for Quality Assurance or its successor:
(1) A managed care organization that has contracted with the office before July 1, 2008, to provide Medicaid services under a risk based managed care program.
(2) A behavioral health managed care organization that has contracted before July 1, 2008, with a managed care organization described in subdivision (1).
(b) A:
(1) managed care organization that has contracted with the office after June 30, 2008, to provide Medicaid services under a risk based managed care program; or
(2) behavioral health managed care organization that has contracted after June 30, 2008, with a managed care organization described in subdivision (1);
must begin the accreditation process and obtain accreditation by the National Committee for Quality Assurance or its successor at the earliest time that the National Committee for Quality Assurance allows a managed care organization to be accredited.
As added by P.L.113-2008, SEC.6. Amended by P.L.152-2017, SEC.20.
2023 Indiana Code › Title 12. Human Services › Article 15. Medicaid › Chapter 12. Managed Care › 12-15-12-22. Accepting, Receiving, and Processing Electronic Claims

Sec. 22. A:
(1) managed care organization that has a contract with the office to provide Medicaid services under a risk based managed care program; or
(2) behavioral health managed care organization that has contracted with a managed care organization described in subdivision (1);
shall accept, receive, and process claims for payment that are filed electronically by a Medicaid provider.
As added by P.L.113-2008, SEC.7. Amended by P.L.152-2017, SEC.21.
2023 Indiana Code › Title 12. Human Services › Article 15. Medicaid › Chapter 12. Managed Care › 12-15-12-23. Psychiatrist Practicing in Community Mental Health Center

Sec. 23. A managed care organization may not require a psychiatrist who is licensed under IC 25-22.5 to be certified by the American Board of Psychiatry and Neurology for purposes of credentialing or contracting with the psychiatrist while the psychiatrist is practicing at a community mental health center.
As added by P.L.264-2019, SEC.3.
2023 Indiana Code › Title 12. Human Services › Article 15. Medicaid › Chapter 13. Provider Payment; General › 12-15-13-0.1. Application of Certain Amendments to Chapter

Sec. 0.1. The amendments made to this chapter apply as follows:
(1) The amendments made to section 1 of this chapter by P.L.257-1996 apply to provider claims for payment under the Medicaid program under this article after March 31, 1996.
(2) The addition of section 1.5 of this chapter by P.L.257-1996 applies to provider claims for payment under the Medicaid program under this article after March 31, 1996.
As added by P.L.220-2011, SEC.266.
2023 Indiana Code › Title 12. Human Services › Article 15. Medicaid › Chapter 13. Provider Payment; General › 12-15-13-0.4. "Office"

Sec. 0.4. As used in this chapter, "office" includes the following:
(1) The office of the secretary of family and social services.
(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. Amended by P.L.109-2014, SEC.19.
2023 Indiana Code › Title 12. Human Services › Article 15. Medicaid › Chapter 13. Provider Payment; General › 12-15-13-0.5. "Clean Claim"

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.
2023 Indiana Code › Title 12. Human Services › Article 15. Medicaid › Chapter 13. Provider Payment; General › 12-15-13-0.6. "Clean Claim" 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.
(D) Revenue codes.
(E) Rate of payment.
(F) Service units.
(G) Total charges.
(H) Provider number.
(I) Third party prior payments.
(J) Estimated amount due.
(K) Recipient number.
(L) Provider signature.
(M) Provider name.
(N) Number of covered days of service.
(O) Date of admission.
(P) Condition codes.
(Q) Occurrence codes and dates.
(R) Value codes and amounts.
(S) Third party liability payor name.
(T) Recipient name.
(U) Admitting diagnosis.
(V) Attending physician ID number.
(2) Has correct and valid information for each of the locators required by subdivision (1).
(3) The recipient for whom the claim is submitted is eligible for Medicaid on the date for which the service is billed.
(4) The office has approved the level of care for:
(A) the recipient; and
(B) the facility;
for the dates for which the service is billed.
(5) The provider is eligible to render service on the date for which the service is billed.
(6) The claim does not duplicate a claim already paid.
(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.3 and P.L.257-1996, SEC.3.
2023 Indiana Code › Title 12. Human Services › Article 15. Medicaid › Chapter 13. Provider Payment; General › 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.
2023 Indiana Code › Title 12. Human Services › Article 15. Medicaid › Chapter 13. Provider Payment; General › 12-15-13-1. Payment, Denial, or Suspension of Claims Submitted by Nursing Facilities; Time; Notice of Suspension or Denial

Sec. 1. (a) This section applies only to claims submitted for payment by nursing facilities.
(b) The office shall pay, deny, or suspend each claim submitted by a provider for payment under the Medicaid program not more than:
(1) twenty-one (21) days after the date a claim that is filed electronically; or
(2) thirty (30) days after the date a claim that is filed on paper;
is received by the office or, if IC 12-15-30 applies, by the contractor under IC 12-15-30.
(c) The office shall pay each clean claim.
(d) The office may deny or suspend a claim that is not a clean claim. If the office denies a provider's claim for payment, the office shall notify the provider of each reason the claim was denied.
(e) If the office suspends a provider's claim for payment under the Medicaid program, the office shall notify the provider of each reason the claim was suspended.
[Pre-1992 Revision Citation: 12-1-7-16.5.]
As added by P.L.2-1992, SEC.9. Amended by P.L.10-1994, SEC.4; P.L.107-1996, SEC.5; P.L.257-1996, SEC.5.
2023 Indiana Code › Title 12. Human Services › Article 15. Medicaid › Chapter 13. Provider Payment; General › 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.
2023 Indiana Code › Title 12. Human Services › Article 15. Medicaid › Chapter 13. Provider Payment; General › 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.
2023 Indiana Code › Title 12. Human Services › Article 15. Medicaid › Chapter 13. Provider Payment; General › 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.
2023 Indiana Code › Title 12. Human Services › Article 15. Medicaid › Chapter 13. Provider Payment; General › 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.
[Pre-1992 Revision Citation: 12-1-7-17.6(a).]
As added by P.L.2-1992, SEC.9. Amended by P.L.278-1993(ss), SEC.27.
2023 Indiana Code › Title 12. Human Services › Article 15. Medicaid › Chapter 13. Provider Payment; General › 12-15-13-3. Repealed

As added by P.L.152-1995, SEC.10. Amended by P.L.107-1996, SEC.9; P.L.257-1996, SEC.9; P.L.78-2004, SEC.3; P.L.8-2005, SEC.1. Repealed by P.L.229-2011, SEC.270.
2023 Indiana Code › Title 12. Human Services › Article 15. Medicaid › Chapter 13. Provider Payment; General › 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 organization;
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 organization 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 organization may not reissue the bulletin or notice for thirty (30) days unless the change is required by the federal government to be implemented earlier.
As added by P.L.42-1995, SEC.22. Amended by P.L.187-2007, SEC.2; P.L.15-2009, SEC.1; P.L.153-2011, SEC.17; P.L.152-2017, SEC.22.
2023 Indiana Code › Title 12. Human Services › Article 15. Medicaid › Chapter 13. Provider Payment; General › 12-15-13-7. Permitted Forms

Sec. 7. (a) The office and an entity with which the office contracts for the payment of claims shall accept claims submitted on any of the following forms by an individual or organization that is a contractor or subcontractor of the office:
(1) CMS-1500 or its subsequent form.
(2) CMS-1450 (UB04) or its subsequent form.
(3) American Dental Association (ADA) claim form.
(4) Pharmacy and compound drug form.
(b) The office and an entity with which the office contracts for the payment of claims:
(1) may designate as acceptable claim forms other than a form listed in subsection (a); and
(2) may not mandate the use of a crossover claim form.
As added by P.L.256-2001, SEC.3. Amended by P.L.27-2011, SEC.2.