Section 405IAC1-1-3. Filing of claims; filing date; waiver of limit; claim auditing; payment liability; third party payments

   (a) All 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. A provider who is dissatisfied with the amount of reimbursement may appeal under the provisions of 405 IAC 1-1.5. However, prior to filing such an appeal, the provider must either:

(1) resubmit the claim if the reason for denial of payment was due to incorrect or inaccurate billing by the provider;

(2) submit, if appropriate, an adjustment request to the office; or

(3) submit a written request to the office, stating why the provider disagrees with the denial or amount of reimbursement.

  (b) 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. All claims filed after twelve (12) months of the date of the provision of the service, as well as claims filed after sixty (60) days of the date of notification that the claim was paid or denied shall be rejected 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:

(1) office error or action that has delayed payment;

(2) reasonable and continuous attempts on the part of the provider to resolve a claim problem;

(3) reasonable and continuous attempts on the part of the provider to first bill and collect from a third party liability source before billing Medicaid; or

(4) failure of Medicare/Medicaid claims to cross over.

  (c) 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:

(1) The provider's records document that the member refused or was physically unable to provide the member's Medicaid number.

(2) The provider can substantiate that the provider continually pursued reimbursement from the patient until such time Medicaid eligibility was discovered.

(3) The provider billed Medicaid, or otherwise contacted Medicaid in writing regarding the situation within sixty (60) days of the date Medicaid eligibility was discovered.

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.

  (d) 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.

  (e) 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 which 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.

  (f) Third party payment is as follows:

(1) Resources from health insurance plans available to the member shall apply first to defraying the cost of medical services before any share of the Medicaid claim for payment is approved. Such resources shall include, but not be limited to, Medicare, Civilian Health and Medical Plan for Uniform Services (CHAMPUS), other health insurances, and Worker's Compensation. A provider of services to a member shall not submit a claim for reimbursement by Medicaid until the provider has first ascertained whether any such resource may be liable for all or part of the cost of the services and has sought reimbursement from that resource. With approval of the office, a Medicaid claim may be paid prior to third party payment when the liability of the third party is yet to be determined through court proceedings, such as in paternity cases, or when the third party payment will not be available for an extended period of time, with recoupment by the office required when such third party resources become available.

(2) Third party payments applied to the member's cost of care shall be deducted from the total payment allowable from Medicaid, with Medicaid paying only the balance. Reimbursement rates are determined by the office according to the requirements of federal and state laws governing rate setting for Medicaid services and shall be accepted as party payor.

  (g) No Medicaid reimbursement shall be available for services provided to individuals who are not eligible Medicaid members on the date the service is provided.

  (h) No Medicaid reimbursement shall be available for services provided outside the parameters of a restricted status (see section 6 of this rule).

  (i) 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 which is not reimbursed by Medicaid except for copayment and any patient liability payment as authorized by law. (See 42 CFR 447.15.) (Office of the Secretary of Family and Social Services; Title 5, Ch 1, Reg 5-103; filed Feb 10, 1978, 11:20 a.m.: Rules and Regs. 1979, p. 250; filed Oct 7, 1982, 3:54 p.m.: 5 IR 2345; filed Mar 14, 1986, 4:35 p.m.: 9 IR 1857; filed Mar 15, 1988, 1:59 p.m.: 11 IR 2850; readopted filed Jun 27, 2001, 9:40 a.m.: 24 IR 3822; readopted filed Sep 19, 2007, 12:16 p.m.: 20071010-IR-405070311RFA; readopted filed Oct 28, 2013, 3:18 p.m.: 20131127-IR-405130241RFA; filed Aug 1, 2016, 3:44 p.m.: 20160831-IR-405150418FRA; errata filed Oct 6, 2016, 2:59 p.m.: 20161019-IR-405160452ACA) NOTE: 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.