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 March 20, 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:
(d) An institutional provider that receives the preliminary recalculated Medicaid rate under subsection (c)(2) may:
(e) If the office believes, after having reviewed an institutional provider's request for reconsideration, that an overpayment occurred, the office shall notify the provider in writing a notice of final calculation of overpayment. An institutional provider may contest the office's final determination by filing an appeal with the office within sixty (60) calendar days from the date of the notice of final calculation.
(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) The deadlines outlined under section 11(f) of this rule shall apply to an appeal filed under this section.
(h) An appeal must include the elements listed under section 11(g) of this rule.
(i) The institutional provider appealing a final calculation of an overpayment must file with the office a statement of issues:
(j) For all other appeal requests, the institutional provider must file with the office a statement of issues:
(k) The provisions of section 11(j) through 11(o) [of this rule] shall apply to a provider's statement of issues.