Indiana Administrative Code
Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES
Article 1 - MEDICAID PROVIDERS AND SERVICES
Rule 1 - General Provisions
Section 1-3 - Filing of claims; filing date; waiver of limit; claim auditing; payment liability; third party payments
Current through March 20, 2024
Authority: IC 12-15-1-10; IC 12-15-1-15; IC 12-15-21-2
Affected: IC 12-13-7-3; IC 12-15
Sec. 3.
(a) For dates of service on or before December 31, 2018, provider claims for payment for services rendered to members must be originally filed with the office within twelve (12) months of the date of the provision of the service.
(b) For dates of service on or after January 1, 2019, provider claims for payment for services rendered to members must be originally filed with the office within one hundred eighty (180) days of the date of the provision of the service.
(c) A provider who is dissatisfied with the amount of reimbursement may appeal under the provisions of 405 IAC 1-1.4. However, prior to filing such an appeal, the provider must either:
(d) All requests for payment adjustments or reconsideration, or both, of a claim that has been denied must be submitted to the office within sixty (60) days of the date of notification that the claim was paid or denied. In order to be considered for payment, each subsequent claim resubmission or adjustment request must be submitted within sixty (60) days of the most recent notification that the claim was paid or denied. The date of notification shall be considered to be three (3) days following the date of mailing from the office.
(e) For dates of service on or before December 31, 2018, claims filed after twelve (12) months of the date of the provision of the service shall be denied for payment unless a waiver has been granted. For dates of service on or after January 1, 2019, claims filed after one hundred eighty (180) days of the date of the provision of the service shall be denied for payment unless a waiver has been granted. Claims filed after sixty (60) days of the date of notification that the claim was paid or denied shall be denied for payment unless a waiver has been granted. In extenuating circumstances a waiver of the filing limit may be authorized by the office when justification is provided to substantiate why the claim could not be filed or refiled within the filing limit. Some examples of situations considered to be extenuating circumstances are:
(f) The fact that the provider was unaware the member was eligible for assistance at the time services were rendered is an acceptable reason for waiving the filing limitation only if the following conditions are met:
In situations in which a patient receives a Medicaid covered service and is subsequently determined to be eligible, a waiver of the filing limit, where necessary, may be granted if the provider bills Medicaid within one (1) year of the date of the retroactive eligibility determination. In situations where a member receives a service outside Indiana by a provider who has not yet been enrolled or has not received a provider manual at the time services were rendered, the claims filing limitation may be waived, subject to approval by the office. Such situations will be reviewed on an individual basis by the office to ascertain if the provider made a good faith effort to enroll and submit claims in a timely manner.
(g) All claims filed for reimbursement shall be reviewed prior to payment by the office for completeness, including required documentation, appropriateness of services and charges, application of third party obligations, statement of prior authorization when required, and other areas of accuracy and appropriateness as indicated.
(h) Medicaid is only liable for the payment of claims filed by providers who were enrolled providers at the time the service was rendered and for services provided to persons who were enrolled in Medicaid as eligible members at the time service was provided. Payment may be made for services rendered during any one (1) or all of the three (3) months preceding the month of Medicaid application if the patient is found to be eligible during such period. Non-enrolled providers giving the retroactive service must file a provider application retroactive to the beginning date of eligible service and meet provider enrollment requirements during the retroactive period. A claim for services that requires prior authorization by the office provided during the retroactive period will not be paid unless such services have been reviewed and approved by the office prior to payment. The claim will not be paid if the services provided are outside the service parameters as established by the office.
(i) Third party payment is as follows:
(j) No Medicaid reimbursement shall be available for services provided to individuals who are not eligible Medicaid members on the date the service is provided.
(k) No Medicaid reimbursement shall be available for services provided outside the parameters of a restricted status.
(l) A Medicaid provider shall not collect from a Medicaid member or from the family of the Medicaid member any portion of the charge for a Medicaid covered service that is not reimbursed by Medicaid except for copayment and any patient liability payment as authorized by law. (See 42 CFR 447.15.)
Transferred from the Division of Family and Children (470 IAC 5-1-3) to the Office of the Secretary of Family and Social Services (405 IAC 1-1-3) by P.L. 9-1991, SECTION 131, effective January 1, 1992.