CHAPTER 21. RULES
IC 12-15-21
Chapter 21. Rules
IC 12-15-21-1
Acceptance by provider of Medicaid claim payment; agreement to
comply with statutes and rules
Sec. 1. A provider who accepts payment of a claim submitted
under the Medicaid program is considered to have agreed to comply
with the statutes and rules governing the program.
As added by P.L.2-1992, SEC.9.
IC 12-15-21-2
Secretary to adopt rules; consistency with Title XIX of Social
Security Act
Sec. 2. The secretary shall, with the advice of the office's medical
staff, adopt rules under IC 4-22-2 and consistent with Title XIX of
the federal Social Security Act (42 U.S.C. 1396 et seq.) and
regulations promulgated under the federal Social Security Act.
As added by P.L.2-1992, SEC.9.
IC 12-15-21-3
Required rules
Sec. 3. The rules adopted under section 2 of this chapter must
include the following:
(1) Providing for prior review and approval of medical services.
(2) Specifying the method of determining the amount of
reimbursement for services.
(3) Establishing limitations that are consistent with medical
necessity concerning the amount, scope, and duration of the
services and supplies to be provided. The rules may contain
limitations on services that are more restrictive than allowed
under a provider's scope of practice (as defined in Indiana law).
(4) Denying payment or instructing the contractor under
IC 12-15-30 to deny payment to a provider for services
provided to an individual or claimed to be provided to an
individual if the office after investigation finds any of the
following:
(A) The services claimed cannot be documented by the
provider.
(B) The claims were made for services or materials
determined by licensed medical staff of the office as not
medically reasonable and necessary.
(C) The amount claimed for the services has been or can be
paid from other sources.
(D) The services claimed were provided to a person other
than the person in whose name the claim is made.
(E) The services claimed were provided to a person who was
not eligible for Medicaid.
(F) The claim rises out of an act or practice prohibited by
law or by rules of the secretary.
(5) Recovering payment or instructing the contractor under
IC 12-15-30-3 to recover payment from a provider for services
rendered to an individual or claimed to be rendered to an
individual if the office after investigation finds any of the
following:
(A) The services paid for cannot be documented by the
provider.
(B) The amount paid for such services has been or can be
paid from other sources.
(C) The services were provided to a person other than the
person in whose name the claim was made and paid.
(D) The services paid for were provided to a person who was
not eligible for Medicaid.
(E) The paid claim rises out of an act or practice prohibited
by law or by rules of the secretary.
(6) Recovering interest due from a provider:
(A) at a rate that is the percentage rounded to the nearest
whole number that equals the average investment yield on
state money for the state's previous fiscal year, excluding
pension fund investments, as published in the auditor of
state's comprehensive annual financial report; and
(B) accruing from the date of overpayment;
on amounts paid to the provider that are in excess of the amount
subsequently determined to be due the provider as a result of an
audit, a reimbursement cost settlement, or a judicial or an
administrative proceeding.
(7) Paying interest to providers:
(A) at a rate that is the percentage rounded to the nearest
whole number that equals the average investment yield on
state money for the state's previous fiscal year, excluding
pension fund investments, as published in the auditor of
state's comprehensive annual financial report; and
(B) accruing from the date that an overpayment is
erroneously recovered by the office until the office restores
the overpayment to the provider.
(8) Establishing a system with the following conditions:
(A) Audits may be conducted by the office after service has
been provided and before reimbursement for the service has
been made.
(B) Reimbursement for services may be denied if an audit
conducted under clause (A) concludes that reimbursement
should be denied.
(C) Audits may be conducted by the office after service has
been provided and after reimbursement has been made.
(D) Reimbursement for services may be recovered if an audit
conducted under clause (C) concludes that the money
reimbursed should be recovered.
As added by P.L.2-1992, SEC.9. Amended by P.L.278-1993(ss),
SEC.28; P.L.42-1995, SEC.23; P.L.107-1996, SEC.10; P.L.8-2005,
SEC.2.
IC 12-15-21-4
Rules not to eliminate type of provider licensed to provide services
Sec. 4. The rules adopted by the secretary may not eliminate a
type of provider licensed to provide Medicaid services.
As added by P.L.2-1992, SEC.9.
IC 12-15-21-5
Rules not to be more restrictive than federal Medicaid
reimbursement requirements
Sec. 5. (a) As used in this section, "facility" refers to an
intermediate care facility for the mentally retarded (ICF/MR) not
operated by a state agency.
(b) The rules adopted by the secretary may not establish eligibility
criteria for Medicaid reimbursement for placement or services in a
facility, including services provided under a Medicaid waiver, that
are more restrictive than federal requirements for Medicaid
reimbursement in a facility or under a Medicaid waiver.
(c) The office may not implement a policy that may not be
adopted as a rule under subsection (b).
As added by P.L.78-1994, SEC.2. Amended by P.L.272-1999,
SEC.41.
IC 12-15-21-6
Amendment of prior authorization rule
Sec. 6. (a) IC 4-22-2 does not apply to a rulemaking procedure
under this section.
(b) The office may amend a rule regarding prior authorization (as
defined in 405 IAC 1-6-2) that appears in the Indiana Administrative
Code on January 1, 1996, to make the prior authorization rule less
restrictive.
(c) If the office amends a prior authorization rule under this
section, the office may later amend the prior authorization rule to
restore, in whole or in part, the prior authorization rule as it was in
effect on January 1, 1996.
(d) An amendment to a prior authorization rule under this section
must comply with the notice requirements set forth in IC 12-15-13-6.
As added by P.L.107-1996, SEC.11.
IC 12-15-21-6.5
Family practice residency program
Sec. 6.5. A family practice residency program may choose to have
the name of the residency program, the primary medical provider, or
both, appear on the Medicaid identification card of a recipient who
is enrolled in a Medicaid managed care program instead of just the
name of the individual primary medical provider in the residency
program to whom the recipient has been assigned.
As added by P.L.107-1996, SEC.12 and P.L.257-1996, SEC.11.
IC 12-15-21-7
Rules not to be more stringent than prior authorization rule
effective January 1, 1996
Sec. 7. The office may not amend a prior authorization rule to
make it more stringent than the prior authorization rule as it was in
effect on January 1, 1996, unless the office changes the rule through
the rulemaking process.
As added by P.L.107-1996, SEC.13.