Section 405IAC1-1.5-1. Scope

   (a) This rule governs the procedures for appeals to the office of Medicaid policy and planning (office) involving actions or determinations of reimbursement for all Medicaid providers.

  (b) This rule governs the procedures for appeals to the office from the following actions or determinations:

(1) Setting rates of reimbursement.

(2) Any action based upon a final audit.

(3) Determination of change of provider status for purposes of setting a rate of reimbursement.

(4) Determination by the office that an overpayment to a provider has been made due to a year-end cost settlement.

(5) Any other determination by the office that a provider has been paid more than it was entitled to receive under any federal or state statute or regulation.

(6) The office's refusal to enter into a provider agreement.

(7) The office's suspension, termination, or refusal to renew an existing provider agreement.

(8) The office's revocation of a qualified hospital's presumptive eligibility provider status under 405 IAC 2-3.3-3.

  (c) Notwithstanding subsections (a) and (b), this rule does not govern determinations by the office or its contractor with respect to the authorization or approval of Medicaid services requested by a provider on behalf of a recipient.

  (d) Disputes relating to claims submitted to a managed care organization (MCO) by providers who are not under contract to the MCO, and who provide services to recipients in the risk-based managed care program are governed by 405 IAC 1-1.6. (Office of the Secretary of Family and Social Services; 405 IAC 1-1.5-1; filed Oct 31, 1994, 3:30 p.m.: 18 IR 862; readopted filed Jun 27, 2001, 9:40 a.m.: 24 IR 3822; filed Nov 10, 2004, 3:15 p.m.: 28 IR 815; errata filed Nov 15, 2004, 10:20 a.m.: 28 IR 970; 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 Sep 14, 2015, 2:07 p.m.: 20151014-IR-405130497FRA)