reglab/statecodes huggingface dataset:
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 1 - MEDICAID PROVIDERS AND SERVICES › Rule 1 - General Provisions › Section 1-8 - Level of care criteria for long-term care facilities; governing provisions

Current through July 10, 2024
Authority: IC 12-15-1-10; IC 12-15-1-15; IC 12-15-21-2
Affected: IC 4-22-2; IC 12-13-7-3; IC 12-15
Sec. 8.
Level of Care Criteria for Long-Term Care Facilities. In
				  accordance with the provisions of IC 12-1-7
[IC 12-1 was repealed by
				  P.L.
				  2-1992,
				  SECTION
				  897, effective February 14, 1992.]
;
				  IC 4-22-2 as amended by Indiana Public Law 38, Acts of 1977; and in
				  conformity with the provisions of Title XIX of the federal Social Security Act
				  and related federal regulations, the state board of public welfare hereby
				  promulgates a document issued by the department on January 5, 1976 as amended
				  in May, 1977, entitled Indiana's Medicaid Program Criteria for Level of Care
				  Provided by Long-Term Care Facilities
[405 IAC
				  1-3]
.
If any provision of the above cited document
[405 IAC 1-3]
is or
				  shall become inconsistent with any other regulation promulgated by the state
				  board of public welfare the provision of this regulation
[405 IAC
				  1-3]
shall govern. If the content of the
				  above cited document
[405 IAC 1-3]
is inconsistent with any subsequently enacted amendment of IC 12-1-7
[IC 12-1 was repealed by
				  P.L.
				  2-1992,
				  SECTION
				  897, effective February 14, 1992.]
or the federal Social Security Act or any regulation promulgated thereunder,
				  the amendment to IC 12-1-7
[IC 12-1 was repealed by
				  P.L.
				  2-1992,
				  SECTION
				  897, effective February 14, 1992.]
or the Social Security Act or the regulation promulgated thereunder shall
				  govern until such time as the above cited document
[405 IAC
				  1-3]
can be amended.
If any part of the Indiana's Medicaid Program Criteria for
				  Level of Care Provided by Long-Term Care Facilities document
[405 IAC 1-3]
or the
				  application of it to any person or circumstance is held invalid, the invalidity
				  does not affect other provisions or applications of the document which can be
				  given effect without the invalid provision or application, and to this end this
				  document is severable.
IC 4-22-2
IC 12-1-2-2(c)
[IC 12-1 was repealed by
				  P.L.
				  2-1992,
				  SECTION
				  897, effective February 14,
				  1992.]
IC 12-1-2-3(f)
[IC 12-1 was repealed by
				  P.L.
				  2-1992,
				  SECTION
				  897, effective February 14,
				  1992.]
IC 12-1-7-15
[Repealed by
				  P.L.
				  70-1978,
				  SECTION
				  3.]
Transferred from the Division of Family and Children
					 (470 IAC 5-1-6) to the Office of
					 the Secretary of Family and Social Services (405 IAC
					 1-1-8) by
					 P.L.
					 9-1991,
					 SECTION
					 131, effective January 1,
					 1992.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 1 - MEDICAID PROVIDERS AND SERVICES › Rule 1 - General Provisions › Section 1-9 - Nursing home admission; governing provisions

Current through July 10, 2024
Authority: IC 12-15-1-10; IC 12-15-1-15; IC 12-15-21-2
Affected: IC 4-22-2; IC 12-13-7-3; IC 12-15
Sec. 9.
Nursing Home Admission. In accordance with the provisions of
				  IC 12-1-7
[IC 12-1 was repealed by
				  P.L.
				  2-1992,
				  SECTION
				  897, effective February 14, 1992.]
;
				  IC 4-22-2 as amended by Indiana Public Law 38, Acts of 1977; and in
				  conformity with the provisions of Title XIX of the federal Social Security Act
				  and related federal regulations, the state board of public welfare hereby
				  promulgates a document issued on June 1, 1976 and amended October 12, 1976 by
				  the department entitled Medicaid DPW Bulletin No. 3.
If any provision of the above cited document is or shall
				  become inconsistent with any other regulation promulgated by the state board of
				  public welfare the provision of this regulation shall govern. If the content of
				  the above cited document is inconsistent with any subsequently enacted
				  amendment of IC 12-1-7
[IC 12-1 was repealed by
				  P.L.
				  2-1992,
				  SECTION
				  897, effective February 14, 1992.]
or the federal Social Security Act or any regulation promulgated thereunder,
				  the amendment to IC 12-1-7
[IC 12-1 was repealed by
				  P.L.
				  2-1992,
				  SECTION
				  897, effective February 14, 1992.]
or the Social Security Act or the regulation promulgated thereunder shall
				  govern until such time as the above cited document can be amended.
If any part of the document Medicaid DPW Bulletin No. 3, as
				  amended, or the application of it to any person or circumstance is held
				  invalid, the invalidity does not affect other provisions or applications which
				  can be given effect without the invalid provision or application, and to this
				  end this document is severable.
IC 4-22-2
IC 12-1-2-2(c)
[IC 12-1 was repealed by
				  P.L.
				  2-1992,
				  SECTION
				  897, effective February 14, 1992.]
IC 12-1-2-3(f)
[IC 12-1 was repealed by
				  P.L.
				  2-1992,
				  SECTION
				  897, effective February 14,
				  1992.]
IC 12-1-7-15
[Repealed by
				  P.L.
				  70-1978,
				  SECTION
				  3.]
Transferred from the Division of Family and Children
					 (470 IAC 5-1-7) to the Office of
					 the Secretary of Family and Social Services (405 IAC
					 1-1-9) by
					 P.L.
					 9-1991,
					 SECTION
					 131, effective January 1,
					 1992.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 1 - MEDICAID PROVIDERS AND SERVICES › Rule 1 - General Provisions › Section 1-10 - Intermediate care for the mentally retarded; governing provisions

Current through July 10, 2024
Authority: IC 12-15-1-10; IC 12-15-1-15; IC 12-15-21-2
Affected: IC 4-22-2; IC 12-13-7-3; IC 12-15
Sec. 10.
Intermediate Care for the Mentally Retarded (ICF/MR). In
				  accordance with provisions of IC 12-1-7
[IC 12-1 was repealed by
				  P.L.
				  2-1992,
				  SECTION
				  897, effective February 14, 1992.]
;
				  IC 4-22-2 as amended by Indiana Public Law 38, Acts of 1977; and in
				  conformity with the provisions of Title XIX of the federal Social Security Act
				  and related federal regulations, the state board of public welfare hereby
				  promulgates a document issued on August 15, 1977 by the department entitled
				  Medicaid Bulletin-Intermediate Care for the Mentally Retarded (ICF/MR)
[405 IAC 1-1-9]
.
If any provision of the above cited document
[405 IAC 1-1-9]
is or
				  shall become inconsistent with any other regulation promulgated by the state
				  board of public welfare, the provision of this regulation
[405 IAC 1-1-9]
shall
				  govern. If the content of the above document is inconsistent with any
				  subsequently enacted amendment of IC 12-1-7
[IC 12-1 was repealed by
				  P.L.
				  2-1992,
				  SECTION
				  897, effective February 14, 1992.]
or the federal Social Security Act or any regulation promulgated thereunder,
				  the amendment to IC 12-1-7
[IC 12-1 was repealed by
				  P.L.
				  2-1992,
				  SECTION
				  897, effective February 14, 1992.]
or the Social Security Act or the regulation promulgated thereunder shall
				  govern until such time as the above cited document
[405 IAC
				  1-1-9]
can be amended.
If any part of the document
[405 IAC
				  1-1-9]
cited above or the application of it
				  to any person or circumstance is held invalid, the invalidity does not affect
				  other provisions or applications which can be given effect without the invalid
				  provision or application, and to this end this document is severable.
IC 4-22-2
IC 12-1-2-2(c)
[IC 12-1 was repealed by
				  P.L.
				  2-1992,
				  SECTION
				  897, effective February 14,
				  1992.]
IC 12-1-2-3(f)
[IC 12-1 was repealed by
				  P.L.
				  2-1992,
				  SECTION
				  897, effective February 14,
				  1992.]
IC 12-1-7-15
[Repealed by
				  P.L.
				  70-1978,
				  SECTION
				  3.]
Transferred from the Division of Family and Children
					 (470 IAC 5-1-8) to the Office of
					 the Secretary of Family and Social Services (405 IAC
					 1-1-10) by
					 P.L.
					 9-1991,
					 SECTION
					 131, effective January 1,
					 1992.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 1 - MEDICAID PROVIDERS AND SERVICES › Rule 1 - General Provisions › Section 1-11 - Intermediate care for the mentally retarded; eligibility

Current through July 10, 2024
Authority: IC 12-15-1-10; IC 12-15-1-15; IC 12-15-21-2
Affected: IC 12-13-7-3; IC 12-15
Sec. 11.
Intermediate Care for the Mentally Retarded (ICF/MR) is to
				  be provided for persons in an institution which meets the Federal certification
				  standards to participate as an eligible Medicaid provider. Intermediate care
				  services are designed for persons who are mentally retarded or with certain
				  other conditions as specified herein. The services and/or treatment programs
				  are delivered on an in-patient basis and under the direction and supervision of
				  the required professional staff. Admissions to Intermediate Care Facilities for
				  the Mentally Retarded must be based upon a determination of the need for such
				  care by an interdisciplinary professional team. Approval by the State
				  Department of Public Welfare-Medicaid Division, must be received by the ICF/MR
				  institution prior to admission, or in cases of those individuals who make
				  application while in the institution, prior to payment for that service.
				  Intermediate Care for the Mentally Retarded (ICF/MR) will be provided by the
				  Medicaid program, for eligible persons who must meet these two
				  conditions:
(1) Patient or resident
				has a diagnosis of mental retardation or related conditions of epilepsy,
				cerebral palsy, or other developmental disability found to be closely related
				to mental retardation or to require treatment similar to that required for
				mentally retarded individuals.
(a) Patient or
				resident may be severely or profoundly retarded, moderately retarded, severely
				physically handicapped, aggressive, assaultive, security risk, or manifesting
				severe hyperactive or psychotic-like behavior.
(b) Patient or resident may be moderately
				retarded and may require habit training, training and guidance in the
				activities of daily living, and development of self-help skills for maximum
				independence and as needed by the patient or resident.
(c) Patient or resident may be in vocational
				training programs or adults who work in sheltered workshops.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 1 - MEDICAID PROVIDERS AND SERVICES › Rule 1 - General Provisions › Section 1-12 - Regular access authority to Medicaid division personal information system

Current through July 10, 2024
Authority: IC 12-15-1-10; IC 12-15-1-15; IC 12-15-21-2
Affected: IC 4-1-6-2; IC 12-13-7-3; IC 12-15
Sec. 12.
Regular Access Authority to the Indiana State Department of
				  Public Welfare Medicaid Division Personal Information System. The following
				  individuals have regular access authority to the information contained in the
				  personal information systems maintained by the Medicaid Division of the Indiana
				  State Department of Public Welfare, subject to the confidentiality requirements
				  in State Department of Public Welfare Regulation 1-201
[470 IAC
				  1-3-1]
.
(1) Employees of the Indiana State Department
				of Public Welfare.
(2) Employees of
				the County Welfare Departments of the State of Indiana.
(3) Employees of other agencies of the State
				of Indiana which have been given the responsibility of administering any part
				of the programs set forth in State Department of Public Welfare Regulation
				1-201
[470 IAC 1-3-1]
.
(4) All officials and
				their staffs who are charged by law with the responsibility of pursuing
				criminal and/or civil prosecution.
(5) Employees of the fiscal agent who has
				entered into a contract with the State of Indiana pursuant to IC 12-1-7-17
[Repealed by P.L.
				80-1984,
				SECTION
				10.]
.
(6) Any other individual, agency or official
				whose duties are directly connected with the administration of a plan or
				program approved under Title XIX of the federal Social Security Act, or any
				other federal or federally assisted program which provides assistance, in cash
				or in kind, or services, directly to individuals on the basis of need.
IC 12-1-2-2(c)
[IC 12-1 was repealed by
				  P.L.
				  2-1992,
				  SECTION
				  897, effective February 14,
				  1992.]
IC 12-1-2-3(f)
[IC 12-1 was repealed by
				  P.L.
				  2-1992,
				  SECTION
				  897, effective February 14,
				  1992.]
IC 4-1-6-2
IC 12-1-7-15
[Repealed by
				  P.L.
				  70-1978,
				  SECTION
				  3.]
IC 12-1-7-28
[IC 12-1 was repealed by
				  P.L.
				  2-1992,
				  SECTION
				  897, effective February 14,
				  1992.]
Transferred from the Division of Family and Children
					 (470 IAC 5-1-10) to the Office of
					 the Secretary of Family and Social Services (405 IAC
					 1-1-12) by
					 P.L.
					 9-1991,
					 SECTION
					 131, effective January 1,
					 1992.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 1 - MEDICAID PROVIDERS AND SERVICES › Rule 1 - General Provisions › Section 1-13 - Subrogation of claims

Current through July 10, 2024
Authority: IC 12-15-1-10; IC 12-15-1-15; IC 12-15-21-2
Affected: IC 12-13-7-3; IC 12-15
Sec. 13.
The office shall be subrogated to all claims by Medicaid
				  members against third parties to the extent of Medicaid benefits received by
				  the members, when the direct or proximate cause of the necessity to pay such
				  benefits is the negligence or other legal liability of such third parties.
Transferred from the Division of Family and Children
					 (470 IAC 5-1-11) to the Office of
					 the Secretary of Family and Social Services (405 IAC
					 1-1-13) by
					 P.L.
					 9-1991,
					 SECTION
					 131, effective January 1,
					 1992.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 1 - MEDICAID PROVIDERS AND SERVICES › Rule 1 - General Provisions › Section 1-14 - Severability; governing provisions; effect of provision inconsistent or invalid with federal law

Current through July 10, 2024
Authority: IC 12-15-1-10; IC 12-15-1-15; IC 12-15-21-2
Affected: IC 12-13-7-3; IC 12-15
Sec. 14.
If any provision in this title is or shall become
				  inconsistent with any subsequently enacted amendment to the federal Social
				  Security Act or any regulation promulgated thereunder, the amendment to the
				  Social Security Act or the regulation promulgated thereunder shall govern until
				  such time as this title can be amended. If any part of this title or the
				  application of it to any person, entity, or circumstance is held invalid, the
				  invalidity does not affect other provisions or applications of this title which
				  can be given effect without the invalid provision or application, and to this
				  end the parts of this title are severable.
Transferred from the Division of Family and Children
					 (470 IAC 5-1-12) to the Office of
					 the Secretary of Family and Social Services (405 IAC
					 1-1-14) by
					 P.L.
					 9-1991,
					 SECTION
					 131, effective January 1,
					 1992.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 1 - MEDICAID PROVIDERS AND SERVICES › Rule 1 - General Provisions › Section 1-15 - Third party liability; definitions

Current through July 10, 2024
Authority: IC 12-15-1-10; IC 12-15-1-15; IC 12-15-21-2
Affected: IC 12-13-7-3; IC 12-15
Sec. 15.
(a) The
				following definitions are intended to apply only to this section:
(1) "Certification" means a statement
				authenticated by the seal of the office.
(2) "Coordination of benefits" means all
				activities by which an insurer notifies or is notified by other insurers or
				Medicaid, or both, that a claim has been received, for the purpose of
				establishing primary liability, if previous payment has been made on all or
				part of the claim.
(3) "Final
				settlement" means payment of money from a third party liable for the injury,
				illness, or disease of a member whether by compromise, judgment, court order,
				or restitution, which payment is intended as the total compensation for the
				injury, illness, or disease caused by the liable third party.
(4) "Notice" means a written statement of the
				office's claim bearing:
(A) a certification
				that the person named in the notice is a member of Medicaid; and
(B) the signature of an authorized Medicaid
				employee.
(5) "Office's
				claim" means a statement of Medicaid payments made by the office for any
				Medicaid member that has been certified by an authorized Medicaid
				employee.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 1 - MEDICAID PROVIDERS AND SERVICES › Rule 1 - General Provisions › Section 1-16 - Insurance information; release

Current through July 10, 2024
Authority: IC 12-15-1-10; IC 12-15-1-15; IC 12-15-21-2
Affected: IC 12-13-7-3; IC 12-15-29
Sec. 16.
(a)
				"Insurer" means any insurance company, prepaid health care delivery plan, self
				funded employee benefit plan, pension fund, retirement system, group coverage
				plan, blanket coverage plan, franchise insurance coverage plan, individual
				coverage plan, family-type insurance coverage plan, Blue Cross/Blue Shield
				plan, group practice plan, individual practice plan, labor-management trusteed
				plans, union welfare plans, employer organization plans, employee benefit
				organization plans, governmental program plans, fraternal benefits societies,
				any plan or coverage required or provided by any statute, or similar entity
				that:
(1) is doing business in this state;
				and
(2) is under an obligation to
				make payments for medical services as a result of an injury, illness, or
				disease suffered by a Medicaid member.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 1 - MEDICAID PROVIDERS AND SERVICES › Rule 1.4 - Program Integrity and Appeals › Section 1.4-1 - Scope

Current through July 10, 2024
Authority: IC
				  12-8-6.5-5; IC
				  12-15-1-10; IC
				  12-15-21-3
Affected: IC
				  12-13-7-3; IC 12-15
Sec. 1.
(a) This rule
				outlines the program integrity requirements and appeal procedures relating to
				all claims paid by Medicaid for services rendered and the actions available
				against providers.
(b) This rule
				does not govern determinations by the office with respect to the authorization
				or approval of Medicaid services requested by a provider on behalf of a
				member.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 1 - MEDICAID PROVIDERS AND SERVICES › Rule 1.4 - Program Integrity and Appeals › Section 1.4-2 - Medical records

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-1-15; IC
				  12-15-21-2
Affected: IC
				  12-7-2-38; IC
				  12-13-7-3; IC
				  12-15-13.5-6; IC
				  12-15-22
Sec. 2.
(a) Medicaid
				records shall be:
(1) of sufficient quality to
				fully disclose and document the extent of services provided to individuals
				receiving Medicaid assistance; and
(2) documented at the time the services are
				provided or rendered, and prior to associated claim submission.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 1 - MEDICAID PROVIDERS AND SERVICES › Rule 1.4 - Program Integrity and Appeals › Section 1.4-3 - Provider enrollment

Current through July 10, 2024
Authority: IC 12-15-1-10; IC 12-15-1-15; IC 12-15-21-2
Affected: IC 12-13-7-3; IC 12-15-10-2; IC 12-15-11; IC
				  12-15-12-21; IC 16-31-2-1; IC 20-27
Sec. 3.
(a) In order
				to receive reimbursement under Medicaid, a provider shall be enrolled to
				participate as a provider. A provider is enrolled to participate in Medicaid
				when all of the following conditions have been met:
(1) The provider is duly licensed,
				registered, or certified by the appropriate professional regulatory agency
				pursuant to state or federal law, or otherwise authorized by the
				office.
(2) The provider has
				submitted an application to participate in Medicaid and completed such forms as
				may be required.
(3) The provider
				has signed and returned a Medicaid provider agreement.
(4) The provider has received a provider
				number.
(5) For an institutional or
				individual provider located out-of-state, such entity shall, in addition to
				meeting subdivisions (2) through (4), be either:
(A) certified;
(B) licensed;
(C) registered; or
(D) authorized;
as required by the state in which the entity is
				  located.
(6) The
				provider maintains state licensure and abides by the office's provider
				agreement.
(7) The provider meets
				credentialing standards as required in order for the MCO to receive
				accreditation through the National Committee for Quality Assurance pursuant to
				IC 12-15-12-21.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 1 - MEDICAID PROVIDERS AND SERVICES › Rule 1.4 - Program Integrity and Appeals › Section 1.4-4 - Sanctions against providers; determination after investigation

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-1-15; IC
				  12-15-21-2
Affected: IC
				  4-21.5-3-6; IC
				  4-21.5-3-7; IC
				  4-21.5-4; IC 12-15
Sec. 4.
(a) If, after
				investigation by the office, the IMFCU, or other governmental authority, the
				office determines that a provider has violated any provision of IC 12-15, or
				has violated any rule established under one (1) of those sections, the office
				may impose one (1) or more of the following sanctions:
(1) Deny payment to the provider for Medicaid
				services rendered during a specified period of time as provided under section 8
				of this rule.
(2) Reject a
				prospective provider's application for participation in Medicaid.
(3) Remove a provider's certification for
				participation in Medicaid (decertify the provider).
(4) Assess a fine against the provider in an
				amount not to exceed three (3) times the amounts paid to the provider in excess
				of the amounts that were legally due.
(5) Require the provider to create a
				corrective action plan. A corrective action plan must include the following:
(A) A timeline for coming into compliance
				with state or federal requirements.
(B) The names, including title, address, and
				phone number, of persons responsible for ensuring compliance with state or
				federal requirements.
(C) A
				description of the actions the entity will take to come into compliance with
				state or federal requirements.
(D)
				Any other information required by the office.
If, after sixty (60) calendar days following written notice
				  of a request for a corrective action plan by the state, a provider has not
				  submitted a corrective action plan, the provider may be subject to payment
				  withholding or any other sanction under this rule.
(6) Suspend a provider's Medicaid payments in
				whole or in part.
(7) Terminate the
				provider agreement.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 1 - MEDICAID PROVIDERS AND SERVICES › Rule 1.4 - Program Integrity and Appeals › Section 1.4-5 - Payment suspension procedures

Current through July 10, 2024
Authority: IC 12-8-6.5-5; IC 12-15-1-10; IC 12-15-1-15; IC
				  12-15-21-2
Affected: IC 4-21.5-3-7; IC 4-21.5-4
Sec. 5.
(a) This rule
				applies to a credible allegation of fraud defined in
				42 CFR
				455.2. The office will investigate an
				allegation of fraud it receives from any source. If, during the course of its
				investigation, the office determines that there is a credible allegation of
				fraud against a provider, the office shall:
(1) refer the case to the IMFCU;
				and
(2) suspend Medicaid payments
				pursuant to 42 CFR
				455.23 and the requirements
				therein.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 1 - MEDICAID PROVIDERS AND SERVICES › Rule 1.4 - Program Integrity and Appeals › Section 1.4-6 - Provider exclusions

Current through July 10, 2024
Authority: IC 12-15-1-10; IC 12-15-1-15; IC 12-15-21-2
Affected: IC 4-21.5-3-6; IC 4-21.5-3-7; IC 4-21.5-4; IC
				  12-15-1-22; IC 35-48-1-9
Sec. 6.
(a) The
				following definitions apply throughout this section:
(1) "Business relationship" means an entity
				or individual that meets one (1) or more of the following:
(A) Has a direct or indirect ownership
				interest of five percent (5%) or more in the provider.
(B) Is the owner of a whole or part interest
				in any mortgage, deed or trust, note or other obligation secured (in whole or
				in part) by the provider or any of the property assets thereof, in which whole
				or part interest is equal to or exceeds five percent (5%) of the total property
				and assets of the provider.
(C) Is
				an officer or director of the provider, if the provider is organized as a
				partnership.
(D) Is an agent of the
				provider.
(E) Is a managing
				employee who is:
(i) a general
				manager;
(ii) a business
				manager;
(iii) an administrator;
				or
(iv) a director;
who exercises operational or managerial control over the
				  provider or part thereof, or directly or indirectly conducts the day-to-day
				  operations of the provider or part thereof.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 1 - MEDICAID PROVIDERS AND SERVICES › Rule 1.4 - Program Integrity and Appeals › Section 1.4-7 - Prepayment review

Current through July 10, 2024
Authority: IC 12-15-1-10; IC 12-15-1-15; IC 12-15-21-2
Affected: IC 4-21.5-3-7; IC 4-21.5-4
Sec. 7.
(a)
				Prepayment review is a manual claims review process that allows for:
(1) review of claims for appropriate coding
				and documentation; and
(2)
				education on appropriate billing practices.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 1 - MEDICAID PROVIDERS AND SERVICES › Rule 1.4 - Program Integrity and Appeals › Section 1.4-8 - Denial of claim payment procedures

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-1-15; IC
				  12-15-21-2
Affected: IC
				  4-21.5-3-7; IC
				  4-21.5-4
Sec. 8.
(a) The
				office may deny payment to any provider for Medicaid services rendered,
				including materials furnished to any individual or claimed to be rendered or
				furnished to any individual, if, after investigation by the office, the IMFCU,
				or other governmental authority, the office finds any of the following:
(1) The claims were made for services or
				materials determined by the office, the IMFCU, or other governmental authority
				as not medically necessary.
(2) The
				amount claimed for such services or materials has been paid from other sources
				or is subject to third party liability.
(3) The services claimed were provided to a
				person who was not eligible for Medicaid at the time of the provision of the
				service.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 1 - MEDICAID PROVIDERS AND SERVICES › Rule 1.4 - Program Integrity and Appeals › Section 1.4-9 - Provider audits; overpayments; recovery

Current through July 10, 2024
Authority: IC 12-15-1-10; IC 12-15-21-2; IC 12-15-21-3
Affected: IC 4-6-10; IC 4-21.5-3; IC 12-15-1; IC 12-15-6-5;
				  IC 12-15-13-3.5; IC 12-15-13-4; IC 12-15-21-3; IC 12-15-23-2
Sec. 9.
(a) Under IC
				12-15-21-3(5) and IC 12-15-21-3(7), the office may recover payment from any
				provider for services rendered to an individual, or claimed to be rendered to
				an individual, if the office, after investigation or audit, finds that:
(1) the services paid for cannot be
				documented by the provider as required by section 2 of this rule;
(2) the amount paid for such services has
				been paid from other sources or is subject to third party liability;
(3) the services were provided to a person
				other than the person in whose name the claim was made and paid;
(4) the service reimbursed was provided to a
				person who was not eligible for Medicaid at the time of the provision of the
				service;
(5) the paid claim arises
				out of any act or practice prohibited by law or by rules of the
				office;
(6) the overpayment
				resulted from:
(A) an inaccurate description
				of services or an inaccurate usage of procedure codes;
(B) the provider's itemization of services
				rather than submission of one (1) billing for a related group of services
				provided to a recipient (global billing) as set out in the office's medical
				policy;
(C) duplicate billing;
				or
(D) claims for services or
				materials determined to have been not medically reasonable or necessary;
				or
(7) the overpayment
				to the provider resulted from any other reason not specified in this
				subsection.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 1 - MEDICAID PROVIDERS AND SERVICES › Rule 1.4 - Program Integrity and Appeals › Section 1.4-10 - Provider payments during pendency of applicant or member appeals; recovery

Current through July 10, 2024
Authority: IC 12-15-21-2; IC 12-15-21-3
Affected: IC 12-15-13-2; IC 12-15-13-3.5; IC
				  12-15-13-4
Sec. 10.
(a) The
				office may recover payment from any provider listed in subsection (c) for
				services rendered to an individual if such services are determined to have been
				not medically necessary or not reasonable or otherwise inappropriate. Recovery
				of payments may be made as follows:
(1) When
				the office is required by 42
				CFR 431.230(a) to maintain
				services to a member during the pendency of an appeal, and the hearing decision
				is favorable to the office.
(2)
				When the office has been required, under
				42 CFR
				431.246, to make corrective payments
				following an evidentiary hearing decision favorable to the appellant, and the
				secretary or the secretary's designee thereafter renders a decision favorable
				to the office at administrative review.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 1 - MEDICAID PROVIDERS AND SERVICES › Rule 1.4 - Program Integrity and Appeals › Section 1.4-11 - Appeal requests; noninstitutional providers

Current through July 10, 2024
Authority: IC
				  12-15-21
Affected: IC
				  4-21.5-3; IC
				  12-8-6.5-6; IC
				  12-15-13-3.5
Sec. 11.
(a) Appeals
				governed by this rule will be held in accordance with IC
				4-21.5-3, except as specifically
				set out in this rule. In accordance with IC
				12-8-6.5-6, the office is the
				ultimate authority for purposes of this section.
(b) As used in this section, a
				"noninstitutional provider" means any Medicaid provider defined in IC
				12-15-13-3.5.
(c) Under IC
				12-15-13-3.5, if the office
				believes that an overpayment to a noninstitutional provider has occurred, the
				office may submit a written notice of preliminary draft audit finding of
				overpayment to the provider. A noninstitutional provider that receives the
				preliminary audit findings may:
(1) request
				administrative reconsideration of the preliminary audit findings within
				forty-five (45) calendar days from the date of the notice of preliminary
				findings, along with all comments and additional documentation to support the
				request; or
(2) submit a written
				statement waiving the right to request administrative reconsideration or an
				appeal and accepting the preliminary calculations as final.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 1 - MEDICAID PROVIDERS AND SERVICES › Rule 1.4 - Program Integrity and Appeals › Section 1.4-12 - Appeal requests; institutional providers

Current through July 10, 2024
Authority: IC
				  12-15-21
Affected: IC
				  4-21.5-3; IC
				  12-8-6.5-6; IC
				  12-15-13-4
Sec. 12.
(a) Appeals
				governed by this rule will be held in accordance with IC
				4-21.5-3, except as specifically
				set out in this rule. The ultimate authority for purposes of this section is
				the office in accordance with IC
				12-8-6.5-6.
(b) As used in this section, an
				"institutional provider" means any Medicaid provider defined in IC
				12-15-13-4.
(c) Under IC
				12-15-13-4, if the office believes
				that an overpayment to an institutional provider has occurred, the office may:
(1) submit a written notice of preliminary
				draft audit findings of overpayment to the provider; and
(2) accept and consider any written comments
				submitted by the institutional provider regarding the preliminary draft audit
				and finalize the audit findings and issue a preliminary recalculated Medicaid
				rate.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 1 - MEDICAID PROVIDERS AND SERVICES › Rule 1.4 - Program Integrity and Appeals › Section 1.4-13 - Summary review

Current through July 10, 2024
Authority: IC
				  12-15-21
Affected: IC
				  4-21.5-3
Sec. 13.
(a) The
				office shall provide a summary review of certain issues set out in the
				provider's statement of issues. Issues in the provider's statement of issues
				that challenge the propriety of all or part of the general methodology or
				criteria utilized by the office for:
(1)
				setting rates;
(2)
				audits;
(3) making determinations
				with respect to change of provider status for purposes of setting a rate of
				reimbursement; or
(4) determination
				that an overpayment has been made to a provider due to a year-end
				cost-settlement; shall be certified for summary review by the
				secretary.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 1 - MEDICAID PROVIDERS AND SERVICES › Rule 1.6 - Managed Care Provider Reimbursement Dispute Resolution › Section 1.6-1 - Scope

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-21-2; IC
				  12-15-21-3
Affected: IC 12-15
Sec. 1.
(a) This rule
				applies to disputes relating to claims submitted to risk-based managed care
				organizations (MCOs) contracted with the office by providers who are not
				contracted with the MCO and who provide services to a Medicaid member enrolled
				in a risk-based managed care plan.
(b) This rule governs the procedures for a
				provider's objection to a determination by the MCO involving the provider's
				claim, including a provider's objection to:
(1) any determination by the MCO regarding
				payment for a claim submitted by the provider, including the amount of such
				payment; or
(2) the MCO's
				determination that a claim submitted by the provider lacks sufficient
				supporting information, records, or other materials.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 1 - MEDICAID PROVIDERS AND SERVICES › Rule 1.6 - Managed Care Provider Reimbursement Dispute Resolution › Section 1.6-2 - Informal objection

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-21-2; IC
				  12-15-21-3
Affected: IC 12-15
Sec. 2.
(a) The
				provider may make verbal inquiries at any time to resolve a claim matter.
				Before the provider may submit a formal claim appeal under section 3 of this
				rule, the provider shall attempt to informally resolve the matter as described
				in this section.
(b) The informal
				dispute process shall be commenced by a provider submitting a written objection
				to the MCO, within the following time limits:
(1) If the provider disagrees with the MCO's
				determination regarding the provider's claim, the informal process must be
				commenced within sixty (60) days after the provider's receipt of written
				notification of the MCO's determination.
(2) If the MCO fails to make a determination
				within thirty (30) days of the date the claim was submitted, the informal
				process must be commenced within ninety (90) days of the date the claim was
				submitted to the MCO.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 1 - MEDICAID PROVIDERS AND SERVICES › Rule 1.6 - Managed Care Provider Reimbursement Dispute Resolution › Section 1.6-3 - Formal appeal to managed care organization

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-21-2; IC
				  12-15-21-3
Affected: IC 12-15
Sec. 3.
(a) In the
				event the matter is not resolved to the provider's satisfaction within thirty
				(30) days after the provider commenced the informal process set out in section
				2 of this rule, the provider shall have sixty (60) days after the end of the
				thirty (30) day period to submit a formal appeal notice to the MCO.
(b) The provider's claim appeal notice must
				be in writing and specify the basis of the provider's dispute with the
				MCO.
(c) The formal claim appeal
				procedure is commenced by the MCO's receipt of the provider's written claim
				appeal notice. The appeal review is conducted by a panel of one (1) or more
				individuals selected by the MCO. The panel shall:
(1) be knowledgeable about the policy, legal,
				and clinical issues involved in the matter subject to the appeal;
(2) not include an individual who has been
				involved in any previous consideration of the matter; and
(3) consider all information and material
				submitted to it by the provider that bears directly upon an issue involved in
				the matter.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 1 - MEDICAID PROVIDERS AND SERVICES › Rule 1.6 - Managed Care Provider Reimbursement Dispute Resolution › Section 1.6-4 - Arbitration

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-21-2; IC
				  12-15-21-3
Affected: IC 12-15; IC
				  34-57-2
Sec. 4.
(a) If the
				provider is dissatisfied with the decision of the MCO panel, the provider may
				submit the matter to binding arbitration. The binding arbitration process must
				be conducted in accordance with the rules and regulations of the American
				Health Lawyers Association (AHLA), pursuant to the Uniform Arbitration Act as
				adopted in the state of Indiana at IC
				34-57-2, unless:
(1) the provider and MCO mutually agree to
				some other binding resolution procedure; or
(2) the MCO or providers are subject to
				statutorily imposed arbitration procedures for the resolution of these claims.
				In that case, the statutorily imposed arbitration procedures shall be
				followed.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 1 - MEDICAID PROVIDERS AND SERVICES › Rule 1.6 - Managed Care Provider Reimbursement Dispute Resolution › Section 1.6-5 - Supporting documentation for claims; final determination

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-21-2; IC
				  12-15-21-3
Affected: IC 12-15
Sec. 5.
(a) A claim
				that is finally determined through the claim resolution procedure not to lack
				sufficient supporting documentation shall be processed by the MCO within thirty
				(30) days after such final determination.
(b) If it is finally determined that a claim
				lacks sufficient supporting documentation, the provider shall have thirty (30)
				days after receipt of written notice of the final determination to submit the
				requisite supporting documentation. The claim shall be processed by the MCO
				within thirty (30) days after the provider submits to the MCO the required
				supporting documentation.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 1 - MEDICAID PROVIDERS AND SERVICES › Rule 1.6 - Managed Care Provider Reimbursement Dispute Resolution › Section 1.6-6 - Record keeping and reporting requirements

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-21-2; IC
				  12-15-21-3
Affected: IC 12-15
Sec. 6.
The MCO shall maintain a log of all written informal
				  provider objections to determinations and formal provider appeals involving
				  claims. The logged information shall include the:
(1) provider's name;
(2) date of objection;
(3) nature of the objection; and
(4) disposition.
The MCO shall submit quarterly reports to the office
				  regarding the number and type of provider objections and appeals.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 1 - MEDICAID PROVIDERS AND SERVICES › Rule 3 - Criteria for Level of Care in Long Term Care Facilities › Section 3-1 - Skilled nursing services; unskilled services

Current through July 10, 2024
Authority: IC 12-15-1-1; IC 12-15-1-10
Affected: IC 12-15-5-1
Sec. 1.
(a) Skilled
				nursing services, as ordered by a physician, must be required and provided on a
				daily basis, essentially seven (7) days a week.
(b) Rehabilitation services for an acute
				rehabilitative condition may be provided at either skilled or intermediate
				level of care, depending upon the resident's overall condition and nursing care
				needs. To qualify to skilled rehabilitation services, the following conditions
				shall be met:
(1) The services are ordered by
				a physician and must be required and provided at least five (5) days a
				week.
(2) The therapy must be of
				such complexity and sophistication that the judgment, knowledge, and skills of
				a licensed therapist are required.
(3) The overall condition of the patient must
				be such that the judgment, knowledge, and skills of a licensed therapist are
				required.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 1 - MEDICAID PROVIDERS AND SERVICES › Rule 3 - Criteria for Level of Care in Long Term Care Facilities › Section 3-2 - Intermediate level of care criteria

Current through July 10, 2024
Authority: IC 12-15-1-1; IC 12-15-1-10
Affected: IC 12-15-5-1
Sec. 2.
(a)
				Intermediate nursing care includes care for patients with long term illnesses
				or disabilities which are relatively stable, or care for patients nearing
				recovery and discharge who continue to require some professional medical or
				nursing supervision and attention. Intermediate care services encompass a range
				of services from those below skilled level services to those above room and
				board level services. The determination of the differences between the skilled
				and intermediate level of care is based upon the patient's condition, along
				with the complexity and range of medical services required by the patient on a
				daily basis. The provision of room, food, laundry, and supervision of
				activities of daily living do not, in and of themselves, qualify as
				intermediate care.
(b) Intermediate
				care includes room, food, laundry, and professional supervision of activities
				for protection and safety, along with combinations of the following:
(1) Assistance with ambulation.
(2) Assistance with transfers and
				positioning.
(3) Assistance with
				general bathing and hygiene.
(4)
				Assistance with eating.
(5)
				Assistance with dressing.
(6)
				Assistance with toileting/incontinence care.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 1 - MEDICAID PROVIDERS AND SERVICES › Rule 4 - Rate-Setting Criteria for State-Owned Intermediate Care Facilities for the Mentally Retarded › Section 4-3 - Accounting records; retention schedule; audit trail; accrual basis; segregation of accounts by nature of business and by location (Repealed)

Current through July 10, 2024
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 1 - MEDICAID PROVIDERS AND SERVICES › Rule 4 - Rate-Setting Criteria for State-Owned Intermediate Care Facilities for the Mentally Retarded › Section 4-4 - Financial report to department; annual schedule; prescribed form; extensions; penalty for untimely filing (Repealed)

Current through July 10, 2024
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 1 - MEDICAID PROVIDERS AND SERVICES › Rule 4 - Rate-Setting Criteria for State-Owned Intermediate Care Facilities for the Mentally Retarded › Section 4-5 - New provider; initial financial report to department; criteria for establishing initial interim rates; supplemental report; base rate setting (Repealed)

Current through July 10, 2024
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 1 - MEDICAID PROVIDERS AND SERVICES › Rule 4 - Rate-Setting Criteria for State-Owned Intermediate Care Facilities for the Mentally Retarded › Section 4-6 - Active providers; rate review; annual request; additional requests; requests due to change in law; request concerning capital return factor; computation of factor (Repealed)

Current through July 10, 2024
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 1 - MEDICAID PROVIDERS AND SERVICES › Rule 4 - Rate-Setting Criteria for State-Owned Intermediate Care Facilities for the Mentally Retarded › Section 4-7 - Request for rate review; budget component; occupancy level assumptions; effect of inflation assumptions (Repealed)

Current through July 10, 2024
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 1 - MEDICAID PROVIDERS AND SERVICES › Rule 4 - Rate-Setting Criteria for State-Owned Intermediate Care Facilities for the Mentally Retarded › Section 4-8 - Limitations or qualifications to Medicaid reimbursement; advertising; vehicle basis (Repealed)

Current through July 10, 2024
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 1 - MEDICAID PROVIDERS AND SERVICES › Rule 4 - Rate-Setting Criteria for State-Owned Intermediate Care Facilities for the Mentally Retarded › Section 4-10 - Computation of rate; allowable costs; review of cost reasonableness (Repealed)

Current through July 10, 2024
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 1 - MEDICAID PROVIDERS AND SERVICES › Rule 4 - Rate-Setting Criteria for State-Owned Intermediate Care Facilities for the Mentally Retarded › Section 4-13 - Allowable cost; capital return factor; computation of use fee component; interest; allocation of loan to facilities and parties (Repealed)

Current through July 10, 2024
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 1 - MEDICAID PROVIDERS AND SERVICES › Rule 4 - Rate-Setting Criteria for State-Owned Intermediate Care Facilities for the Mentally Retarded › Section 4-14 - Allowable costs; capital return factor; computation of return on equity component (Repealed)

Current through July 10, 2024
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 1 - MEDICAID PROVIDERS AND SERVICES › Rule 4 - Rate-Setting Criteria for State-Owned Intermediate Care Facilities for the Mentally Retarded › Section 4-15 - Allowable costs; capital return factor; use fee; depreciable life; property basis (Repealed)

Current through July 10, 2024
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 1 - MEDICAID PROVIDERS AND SERVICES › Rule 4 - Rate-Setting Criteria for State-Owned Intermediate Care Facilities for the Mentally Retarded › Section 4-16 - Capital return factor; basis; historical cost; mandatory record keeping; valuation (Repealed)

Current through July 10, 2024