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 March 20, 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:
(d) If the office determines, after having reviewed a noninstitutional provider's timely request for reconsideration, that an overpayment occurred, the office shall notify the provider in writing of the final calculation of overpayment. A noninstitutional provider may contest the office's determination by filing an appeal with the office within sixty (60) calendar days from the date of the notice of final calculation of overpayment.
(e) The noninstitutional provider appealing a final calculation of an overpayment must file with the office a statement of issues:
(f) All other appeal requests governed by this rule must be filed with the ultimate authority within fifteen (15) calendar days of receipt of the determination by the office, in accordance with IC 4-21.5-3-7.
(g) For all other appeal requests, the noninstitutional provider must file with the office a statement of issues:
(h) If a deadline for filing under this section is a:
(i) An appeal filed under this section must state facts demonstrating that the petitioner is:
(j) The statement of issues shall set out in detail:
(k) The statement of issues shall govern the scope of the issues to be adjudicated in the appeal under this rule. The provider will not be permitted to expand the appeal beyond the statement of issues with respect to the:
(l) The provider may supplement or modify its statement of issues for good cause shown, up to sixty (60) calendar days after the appeal request is mailed to the office. The administrative law judge assigned to hear the appeal will determine good cause.
(m) Within thirty (30) days after filing a petition for review, and upon a finding of good cause by the administrative law judge, a hospital appealing an action described in IC 4-21.5-3-6(a)(3) and IC 4-21.5-3-6(a)(4) may amend the statement of issues contained in a petition for review to add one (1) or more additional issues.
(n) Failure of the provider to timely file a statement of issues within the timelines provided in subsections (e) and (g) will result in automatic certification to the secretary for summary review, in accordance with section 13 of this rule.
(o) Notwithstanding subsections (h) through (k), a hospital provider that files an appeal after a determination regarding year-end cost settlement may preserve any Medicaid issues that are affected by any Medicare appeal issues, by indicating in its statement of issues that Medicare issues timely filed before the fiscal intermediary are also preserved in its Medicaid statement of issues.