Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 1 - MEDICAID PROVIDERS AND SERVICES › Rule 14.6 - Rate-Setting Criteria for Nursing Facilities › Section 14.6-22 - Administrative reconsideration; appeal

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-21-3
Affected: IC
				  4-21.5-3; IC
				  12-13-7-3; IC 12-15
Sec. 22.
(a) The
				office shall notify each provider of the provider's rate after such rate has
				been computed. If the provider disagrees with the rate the provider may request
				an administrative reconsideration by the office. Such reconsideration request
				shall be in writing and shall contain specific issues to be reconsidered and
				the rationale for the provider's position. The provider must request
				administrative reconsideration before filing an appeal. Only issues raised by
				the provider during the administrative reconsideration may be subsequently
				raised in an appeal. The request shall be signed by the provider or the
				authorized representative of the provider and must be received by the office
				not later than forty-five (45) days after release of the rate as computed by
				the office. Upon receipt of the request for reconsideration, the office shall
				evaluate the data. After review, the office may amend the rate, amend the
				challenged procedure or affirm the original decision. The office shall
				thereafter notify the provider of its final decision in writing, not later than
				forty-five (45) days from the office's receipt of the request for
				reconsideration. In the event that a timely response is not made by the office
				to the provider's reconsideration request, the request shall be deemed denied
				and the provider may pursue its administrative remedies as set out in
				subsection (d).
(b) If the provider
				disagrees with the preliminary recalculated Medicaid rate resulting from a
				financial audit adjustment or reportable condition the provider may request an
				administrative reconsideration from the office. Such reconsideration request
				shall be in writing and shall contain specific issues to be considered and the
				rationale for the provider's position. The provider must request administrative
				reconsideration before filing an appeal. Only issues raised by the provider
				during the administrative reconsideration may be subsequently raised in an
				appeal. The request shall be signed by the provider or authorized
				representative of the provider and must be received by the office not later
				than forty-five (45) days after release of the preliminary recalculated
				Medicaid rate computed by the office. Upon receipt of the request for
				reconsideration, the office shall evaluate the data. After review, the office
				may amend the audit adjustment or reportable condition or affirm the original
				adjustment or reportable condition. The office shall thereafter notify the
				provider of its final decision in writing not later than forty-five (45) days
				from the office's receipt of the request for reconsideration. In the event that
				a timely response is not made by the office to the provider's reconsideration
				request, the request shall be deemed denied and the provider may pursue its
				administrative remedies under subsection (d).
(c) If the provider disagrees with a rate
				redetermination resulting from a recalculation of its CMI due to an MDS review
				affecting the established Medicaid rate, the provider may request an
				administrative reconsideration from the office. Such reconsideration request
				shall be in writing and shall contain specific issues to be considered and the
				rationale for the provider's position. The provider must request administrative
				reconsideration before filing an appeal. Only issues raised by the provider
				during the administrative reconsideration may be subsequently raised in an
				appeal. The request shall be signed by the provider or authorized
				representative of the provider and must be received by the office not later
				than forty-five (45) days after release of the rate computed by the office.
				After review, the office may amend the review adjustment or affirm the original
				adjustment. The office shall thereafter notify the provider of its final
				decision in writing not later than forty-five (45) days from the office's
				receipt of the request for reconsideration. In the event that a timely response
				is not made by the office to the provider's reconsideration request, the
				request shall be deemed denied and the provider may pursue its administrative
				remedies under subsection (d).
(d)
				After completion of the reconsideration procedure under subsection (a), (b), or
				(c), the provider may initiate an appeal under IC
				4-21.5-3. The request for an appeal
				must be signed by the nursing facility provider.
(e) The office may take action to implement
				Medicaid rates without awaiting the outcome of the administrative process, in
				accordance with section 1(d) of this rule.