36-2987

36-2987. Reimbursement for the program

A. For inpatient hospital services, the administration shall reimburse the Indian
health service or a tribal facility based on the reimbursement rates for the Indian
health service as published annually in the federal register. For outpatient services,
the administration shall reimburse the Indian health service or a tribal facility based
on the capped fee-for-service schedule established by the director. If Congress
authorizes one hundred per cent pass-through of title XXI monies for services provided in
an Indian health service facility or a tribal facility, the administration shall
reimburse the Indian health service or the tribal facility with this enhanced federal
funding based on the reimbursement rates for the Indian health service or the tribal
facility as published annually in the federal register.

B. Contractors shall reimburse inpatient and outpatient services based on the
reimbursement methodology established in section 36-2904 or the hospital reimbursement
pilot program established by this state.

C. For services rendered on and after October 1, 1998, the administration and the
contractors shall pay a hospital's rate established according to this section subject to
the following:

1. If the hospital's bill is paid within thirty days after the date the bill was
received, the administration shall pay ninety-nine per cent of the rate.

2. If the hospital's bill is paid after thirty days but within sixty days after the
date the bill was received, the administration shall pay one hundred per cent of the
rate.

3. If the hospital's bill is paid any time after sixty days after the date the bill
was received, the administration shall pay one hundred per cent of the rate plus a fee of
one per cent a month for each month or portion of a month following the sixtieth day of
receipt of the bill until the date of payment.

D. The administration and the contractors shall pay claims pursuant to the
methodology, definitions and time frames specified for clean claims in section 36-2904,
subsection G.

E. The director shall specify enrollment procedures including notice to contractors
of enrollment. The administration shall specify in contract when a person who has been
determined eligible will be enrolled with a contractor and the date on which the
contractor will be financially responsible for health and medical services to the person.

F. The director shall monitor any third party payment collections collected by
contractors and noncontracting providers according to the same procedures specified for
title XIX pursuant to section 36-2903.01, subsection K.

G. On oral or written notice from the member, or the member's parent or legal
guardian, that the member, parent or legal guardian believes a claim should be covered by
the program, a contractor or noncontracting provider shall not do either of the following
unless the contractor or noncontracting provider has verified through the administration
that the person is ineligible for the program, has not yet been determined eligible or,
at the time services were rendered, was not eligible or enrolled in the program:

1. Charge, submit a claim to or demand or otherwise collect payment from a member
or person who has been determined eligible.

2. Refer or report a member or person who has been determined eligible to a
collection agency or credit reporting agency for the failure of the member or person who
has been determined eligible to pay charges for covered services unless specifically
authorized by this article or rules adopted pursuant to this article.

H. The administration may conduct postpayment review of all payments made by the
administration and may recoup any monies erroneously paid. The director may adopt rules
that specify procedures for conducting postpayment review. Contractors may conduct a
postpayment review of all claims paid to providers and may recoup monies that are
erroneously paid.

I. The director or the director's designee may employ and supervise personnel
necessary to assist the director in performing the functions of the program.