Section 405IAC10-11-12. Provider reimbursement; rates

   (a) To receive reimbursement under this section, an entity providing services covered under the employer's ESI plan shall enroll as a provider with the office.

  (b) An entity providing services covered under the employer's ESI plan shall receive reimbursement in accordance with the rates subject to that plan. For services provided to a HIP Link member outlined in section 5(f) of this rule, the provider may receive payment at the reimbursement rate contractually paid under the applicable ESI.

  (c) If the ESI plan does not cover the service but it is a wraparound service, the provider shall be reimbursed for such service at the Medicaid rate as established by the Indiana Medicaid state plan.

  (d) The office shall reimburse a provider for federally qualified health center services at the federally required prospective payment system rate in accordance with 42 CFR 447.371, if such rate is higher than the provider's ESI plan rate.

  (e) An entity seeking reimbursement for any services provided to HIP Link members shall first submit the claims to the ESI plan before sending to the office for processing. Failure to do so shall result in a denial of such claim and other sanctions appropriate. (Office of the Secretary of Family and Social Services; 405 IAC 10-11-12; filed Apr 6, 2016, 11:20 a.m.: 20160504-IR-405150325FRA)