Current through March 20, 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.
(b) Prepayment review of claims is not a
sanction and is not subject to appeal. Providers may be added to or removed
from prepayment review at the discretion of the office. Providers released from
prepayment review may be subject to future follow-up reviews to ensure
continued compliance with the Indiana Administrative Code, any other applicable
rules and regulations, and all rules and guidelines set forth in the Indiana
Health Coverage Programs (IHCP) provider Reference Modules and all other IHCP
publications, including, but not limited to, bulletins and banner
pages.
(c) The office shall
implement prepayment review for a period of six (6) months:
(1) The six (6) month period begins upon the
first successful adjudication of a claim submission under prepayment
review.
(2) As part of the
prepayment review process, providers are required to send supporting
documentation for each claim submission.
(3) If the supporting documentation in
subdivision (2) is not submitted, the claim shall be denied.
(d) During the review period, the
office shall conduct a review of the following:
(1) Services were provided according to
Medicaid policy requirements.
(2)
The billed services were medically necessary, appropriate, and not in excess of
the member's need pursuant to a physician order as documented in policy or
services standards.
(3) The number
of visits and services delivered are logically consistent with the member's
characteristics and circumstances, such as type of illness, age, gender, and
service location.
(4) The provider
and member were Medicaid-eligible on the date the service was
provided.
(5) Prior authorization
was obtained if required by policy.
(6) The provider's staff was qualified as
required by state or federal law.
(7) The provider possessed the proper
license, certification, or other accreditation requirements specific to the
provider's scope of practice and Medicaid policy at the time the service was
provided to the member.
(8) The
claim does not duplicate or conflict with one reviewed previously or currently
being reviewed.
(9) The payment
does not exceed any reimbursement rates or limits in the state plan.
(10) Third-party liability within the
requirements of 42 CFR
433.137 is appropriately billed and accounted
for.
(e) On completion
of the review period:
(1) the office shall
review the provider for release from prepayment review if:
(A) the provider has achieved an eighty-five
percent (85%) or more approval rate on claim submissions for three (3)
consecutive months; and
(B) the
volume of its claim submissions remained within ten percent (10%) of its volume
before prepayment review;
(2) if the provider successfully completes
both requirements under subdivision (1) before the six (6) month deadline, they
may be removed from the prepayment review process at the discretion of the
office;
(3) the provider shall
remain on prepayment review for an additional period of six (6) months, and may
be required to submit a corrective action plan, if it fails to satisfy either
requirement under subdivision (1); and
(4) if after the second six (6) month
interval prescribed under subdivision (3) the provider fails to satisfy the
requirements under subdivision (1), the office may do the following:
(A) Deny payment for medical assistance
services rendered during a specified period of time.
(B) Terminate the provider
agreement.
(C) Require a corrective
action plan.
(D) Impose other
sanctions as provided in section 4 of this rule.
(f) If a provider has been on
prepayment review for twelve (12) months the office may terminate the provider
agreement if:
(1) there has been no billing
activity for six (6) consecutive months; or
(2) the volume of its claim submissions
during the review period was not within ten percent (10%) of its volume before
prepayment review.
