Section 405IAC1-1.5-2. Appeal requests

   (a) Appeals governed by this rule will be held in accordance with IC 4-21.5-3, except as specifically set out in this rule. The ultimate authority for purposes of this section is the secretary of family and social services administration, in accordance with IC 12-8-6-6 [IC 12-8-6 expired under IC 12-8-6-10. See IC 12-8-6.5-6.].

  (b) A request for an appeal must be filed within the following time limits:

(1) A request for an appeal of a determination that an overpayment has occurred must be filed within the time limits set out in IC 12-15-13-3 [IC 12-15-13-3 was repealed by P.L.229-2011, SECTION 270, effective July 1, 2011.].

(2) All other appeal requests governed by this rule must be filed with the ultimate authority within fifteen (15) calendar days of receipt of the determination by the office of Medicaid policy and planning (office), in accordance with IC 4-21.5-3-7. However, any provider subject to administrative review or reconsideration under this article must seek administrative review or reconsideration before filing an appeal request.

  (c) An appeal request must state facts demonstrating that the petitioner is:

(1) a person to whom the order is specifically directed;

(2) aggrieved or adversely affected by the order; or

(3) entitled to review under any law.

Failure of the provider to file the appeal request within the time limits listed in subsection (b) will result in the waiver of any right to appeal from the office's determination.

  (d) The provider must file with the office a statement of issues:

(1) within forty-five (45) calendar days after the provider receives notice of the determination of the office; or

(2) at the time the provider files a timely request for appeal;

whichever is later.

  (e) The statement of issues shall set out in detail:

(1) the specific findings, action, or determinations of the office from which the provider is appealing; and

(2) with respect to each finding, action, or determination:

(A) why the provider believes that the office's determination was in error; and

(B) all statutes or rules supporting the provider's contentions of error.

  (f) The statement of issues shall govern the scope of the issues to be adjudicated in the appeal under this rule. The provider will not be permitted to expand the appeal beyond the statement of issues with respect to the:

(1) specific findings, action, or determination of the office; or

(2) reason or rationale supporting the provider's appeal.

  (g) The provider may supplement or modify its statement of issues for good cause shown, up to sixty (60) calendar days after the appeal request is mailed to the office. The administrative law judge assigned to hear the appeal will determine good cause.

  (h) Within thirty (30) days after filing a petition for review, and upon a finding of good cause by the administrative law judge, a hospital appealing an action described in IC 4-21.5-3-6(a)(3) and IC 4-21.5-3-6(a)(4) may amend the statement of issues contained in a petition for review to add one (1) or more additional issues.

  (i) Failure of the provider to timely file a statement of issues within forty-five (45) calendar days from the date the provider files the appeal request will result in automatic certification to the secretary for summary review, in accordance with section 3 of this rule.

  (j) Notwithstanding subsections (d) through (f), a hospital provider that files an appeal after a determination regarding year-end cost settlement may preserve any Medicaid issues that are affected by any Medicare appeal issues, by indicating in its statement of issues that Medicare issues timely filed before the fiscal intermediary are also preserved in its Medicaid statement of issues. (Office of the Secretary of Family and Social Services; 405 IAC 1-1.5-2; filed Oct 31, 1994, 3:30 p.m.: 18 IR 862; errata filed Feb 28, 1995, 2:30 p.m.: 18 IR 1836; filed Jul 18, 1996, 3:00 p.m.: 19 IR 3374; errata filed Sep 24, 1996, 3:20 p.m.: 20 IR 331; readopted filed Jun 27, 2001, 9:40 a.m.: 24 IR 3822; filed Feb 14, 2005, 10:25 a.m.: 28 IR 2131; readopted filed Sep 19, 2007, 12:16 p.m.: 20071010-IR-405070311RFA; readopted filed Oct 28, 2013, 3:18 p.m.: 20131127-IR-405130241RFA)