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 1.4-8 - Denial of claim payment procedures
Universal Citation: 405 IN Admin Code 1.4-8
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. 8.
(a) The office may deny payment to any provider for Medicaid services rendered, including materials furnished to any individual or claimed to be rendered or furnished to any individual, if, after investigation by the office, the IMFCU, or other governmental authority, the office finds any of the following:
(1) The claims were made for services or
materials determined by the office, the IMFCU, or other governmental authority
as not medically necessary.
(2) The
amount claimed for such services or materials has been paid from other sources
or is subject to third party liability.
(3) The services claimed were provided to a
person who was not eligible for Medicaid at the time of the provision of the
service.
(b) The decision as to denial of payment for a particular claim or claims is at the discretion of the office. This decision shall be final and:
(1) shall be mailed to the provider by United
States mail at the address contained in the office records and on the claims or
transmitted electronically if the provider has elected to receive electronic
remittance advices;
(2) shall be
effective upon receipt; and
(3) may
be administratively appealed under section 11 of this rule.
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