Section 405IAC1-1-4. Denial of claim payment; basis; discretion of assistant secretary

   (a) The office of Medicaid policy and planning (office) may deny payment, or instruct the fiscal contractor to deny payment, to any provider for medical assistance services rendered, including materials furnished to any individual or claimed to be rendered or furnished to any individual, if, after investigation by the office, the office's designee, the Indiana Medicaid Fraud Control Unit (IMFCU), or other governmental authority, the office finds any of the following:

(1) The services claimed cannot be documented by the provider in accordance with 405 IAC 1-5-1.

(2) The claims were made for services or materials determined by licensed medical staff of the office, the office's designee, the IMFCU, or other governmental authority as not medically reasonable and necessary.

(3) The amount claimed for such services or materials has been or can be paid from other sources.

(4) The services claimed were provided to a person other than a person in whose name the claim is made.

(5) The services claimed were provided to a person who was not eligible for medical assistance at the time of the provision of the service.

(6) The claim for medical assistance services or materials arises out of any of the following acts or practices:

(A) Presenting, or causing to be presented, for payment any false or fraudulent claim for services or merchandise.

(B) Submitting, or causing to be submitted, information for the purpose of obtaining greater compensation than that to which the provider is legally entitled.

(C) Submitting, or causing to be submitted, false information for the purpose of meeting prior authorization requirements.

(D) Failure to disclose, or make available to the office, or its authorized agent, records of services provided to Medicaid recipients and records of payments made therefor.

(E) Engaging in a course of conduct or performing an act deemed by the office to be improper or abusive of the Medicaid program or continuing such conduct following notification that the conduct should cease.

(F) Breach of the terms of the Medicaid Provider Certification Agreement or failure to comply with the terms of the Provider Certification on the Medicaid Claim Form.

(G) Overutilizing the Medicaid program by furnishing, or otherwise causing a recipient to receive, service(s) or merchandise not otherwise required or requested by the recipient.

(H) Violating any provision of state or federal Medicaid law or any rule or regulation promulgated pursuant thereto.

(I) Submission of a false or fraudulent application for provider status.

(J) Failure to meet standards required by the state of Indiana or federal law for participating in the Medicaid program.

(K) Charging a Medicaid recipient for covered services over and above that paid for by the office.

(L) Refusal to execute a new Provider Certification Agreement when requested by the office or its fiscal contractor to do so.

(M) Failure to correct deficiencies to provider operations after receiving written notice of these deficiencies from the office.

(N) Failure to repay within sixty (60) days or make acceptable arrangements for the repayment of identified overpayments or otherwise erroneous payments, except as provided in IC 12-15-13-3 [IC 12-15-13-3 was repealed by P.L.229-2011, SECTION 270, effective July 1, 2011.].

(O) Presenting claims for which federal financial participation is not available.

(7) The claim arises out of any act or practice prohibited by rules and regulations of the office.

(8) The provider, any person with an ownership or control interest in the provider entity, or a managing employee is convicted of a criminal offense related to the provision of medical assistance services or submission of claims for payment for such services.

  (b) The decision as to denial of payment for a particular claim or claims is at the discretion of the assistant secretary of the office or his duly authorized representative. This decision shall be final and:

(1) will be mailed to the provider by United States mail at the address contained in the office records and on the claims or transmitted electronically if the provider has elected to receive electronic remittance advices;

(2) will be effective upon receipt; and

(3) may be administratively appealed under section 3 of this rule.

  (c) The decision as to claim payment suspension is at the discretion of the assistant secretary of the office, or his duly authorized representative, and may include any of the following:

(1) The denial of payment for all claims that have been submitted by the provider pending further investigation by the office, the office's designee, the IMFCU, or other governmental authority.

(2) The suspension or withholding of payment on any or all claims of the provider pending an audit or further investigation by the office, the office's designee, the IMFCU, or other governmental authority.

  (d) The decision of the assistant secretary or his duly authorized representative under subsection (c) shall:

(1) be served upon the provider by certified mail, return receipt requested;

(2) contain a brief description of the decision;

(3) become final fifteen (15) days after its receipt; and

(4) contain a statement that any appeal from the decision shall be taken in accordance with IC 4-21.5-3-7 and 405 IAC 1-1.5-2.

  (e) If an emergency exists, as determined by the office, the assistant secretary or his duly authorized representative may issue an emergency directive suspending or withholding payment on any or all claims of the provider pending further investigation by the office, the office's designee, the IMFCU, or other governmental authority under IC 4-21.5-4. Any order issued under this subsection shall:

(1) be served upon the provider by certified mail, return receipt requested;

(2) become effective upon receipt;

(3) include a brief statement of the facts and law that justifies the office's decision to issue an emergency directive; and

(4) contain a statement that any appeal from the decision of the assistant secretary made under this subsection shall be taken in accordance with IC 4-21.5-3-7 and 405 IAC 1-1.5-2.

(Office of the Secretary of Family and Social Services; Title 5, Ch 1, Reg 5-103.1; filed Jun 19, 1979, 2:16 p.m.: 2 IR 1123; filed Sep 29, 1982, 3:14 p.m.: 5 IR 2346; filed Dec 22, 1995, 2:15 p.m.: 19 IR 1074; errata filed Feb 12, 1996, 10:45 a.m.: 19 IR 1373; filed Jul 18, 1996, 3:00 p.m.: 19 IR 3369; 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) NOTE: Transferred from the Division of Family and Children (470 IAC 5-1-3.5) to the Office of the Secretary of Family and Social Services (405 IAC 1-1-4) by P.L.9-1991, SECTION 131, effective January 1, 1992.