Indiana Administrative Code
Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES
Article 1 - MEDICAID PROVIDERS AND SERVICES
Rule 1.6 - Managed Care Provider Reimbursement Dispute Resolution
Section 1.6-1 - Scope

Universal Citation: 405 IN Admin Code 1.6-1

Current through March 20, 2024

Authority: IC 12-15-1-10; IC 12-15-21-2; IC 12-15-21-3

Affected: IC 12-15

Sec. 1.

(a) This rule applies to disputes relating to claims submitted to risk-based managed care organizations (MCOs) contracted with the office by providers who are not contracted with the MCO and who provide services to a Medicaid member enrolled in a risk-based managed care plan.

(b) This rule governs the procedures for a provider's objection to a determination by the MCO involving the provider's claim, including a provider's objection to:

(1) any determination by the MCO regarding payment for a claim submitted by the provider, including the amount of such payment; or

(2) the MCO's determination that a claim submitted by the provider lacks sufficient supporting information, records, or other materials.

(c) The procedures in this rule may, at the election of a provider, be utilized to determine the payment due for a claim in the event the MCO fails, within thirty (30) days after the provider submits the claim, to notify the provider of its determination:

(1) regarding payment for the provider's claim; or

(2) that the provider's claim lacked sufficient supporting information, records, or other materials.

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