Idaho Administrative Code
Title IDAPA 16 - Health and Welfare, Department of
Rule 16.05.07 - THE INVESTIGATION AND ENFORCEMENT OF FRAUD, ABUSE, AND MISCONDUCT
Section 16.05.07.200 - DENIAL OF PAYMENT
Universal Citation: ID Admin Code 16.05.07.200
Current through August 31, 2023
The following are reasons the Department may deny payment. (3-17-22)
01. Billed Services Not Provided or Not Medically Necessary. The Department may deny payment for any and all claims it determines are for items or services: (3-17-22)
a. Not provided or not found by the
Department to be medically necessary. (3-17-22)
b. Not documented to be provided or medically
necessary. (3-17-22)
c. Not
provided under professionally recognized standards of health care.
(3-17-22)
d. Provided as a result
of a prohibited physician referral under 42 CFR Part 411 , Subpart J.
(3-17-22)
02. Contrary to Rules or Provider Agreement. The Department may deny payment when services billed are contrary to Department rules or the provider agreement. (3-17-22)
03. Failure to Provide Immediate Access to Records. The Department may deny payment when the provider does not allow immediate access to records as listed in Section 101 of these rules. (3-17-22)
Disclaimer: These regulations may not be the most recent version. Idaho may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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