CHAPTER 21. RULES

IC 12-15-21
    Chapter 21. Rules

IC 12-15-21-1
Acceptance by provider of Medicaid claim payment; agreement tocomply with statutes and rules
    Sec. 1. A provider who accepts payment of a claim submittedunder the Medicaid program is considered to have agreed to complywith the statutes and rules governing the program.
As added by P.L.2-1992, SEC.9.

IC 12-15-21-2
Secretary to adopt rules; consistency with Title XIX of SocialSecurity Act
    Sec. 2. The secretary shall, with the advice of the office's medicalstaff, adopt rules under IC 4-22-2 and consistent with Title XIX ofthe federal Social Security Act (42 U.S.C. 1396 et seq.) andregulations promulgated under the federal Social Security Act.
As added by P.L.2-1992, SEC.9.

IC 12-15-21-3
Required rules
    Sec. 3. The rules adopted under section 2 of this chapter mustinclude the following:
        (1) Providing for prior review and approval of medical services.
        (2) Specifying the method of determining the amount ofreimbursement for services.
        (3) Establishing limitations that are consistent with medicalnecessity concerning the amount, scope, and duration of theservices and supplies to be provided. The rules may containlimitations on services that are more restrictive than allowedunder a provider's scope of practice (as defined in Indiana law).
        (4) Denying payment or instructing the contractor underIC 12-15-30 to deny payment to a provider for servicesprovided to an individual or claimed to be provided to anindividual if the office after investigation finds any of thefollowing:
            (A) The services claimed cannot be documented by theprovider.
            (B) The claims were made for services or materialsdetermined by licensed medical staff of the office as notmedically reasonable and necessary.
            (C) The amount claimed for the services has been or can bepaid from other sources.
            (D) The services claimed were provided to a person otherthan the person in whose name the claim is made.
            (E) The services claimed were provided to a person who wasnot eligible for Medicaid.
            (F) The claim rises out of an act or practice prohibited bylaw or by rules of the secretary.        (5) Recovering payment or instructing the contractor underIC 12-15-30-3 to recover payment from a provider for servicesrendered to an individual or claimed to be rendered to anindividual if the office after investigation finds any of thefollowing:
            (A) The services paid for cannot be documented by theprovider.
            (B) The amount paid for such services has been or can bepaid from other sources.
            (C) The services were provided to a person other than theperson in whose name the claim was made and paid.
            (D) The services paid for were provided to a person who wasnot eligible for Medicaid.
            (E) The paid claim rises out of an act or practice prohibitedby law or by rules of the secretary.
        (6) Recovering interest due from a provider:
            (A) at a rate that is the percentage rounded to the nearestwhole number that equals the average investment yield onstate money for the state's previous fiscal year, excludingpension fund investments, as published in the auditor ofstate's comprehensive annual financial report; and
            (B) accruing from the date of overpayment;
        on amounts paid to the provider that are in excess of the amountsubsequently determined to be due the provider as a result of anaudit, a reimbursement cost settlement, or a judicial or anadministrative proceeding.
        (7) Paying interest to providers:
            (A) at a rate that is the percentage rounded to the nearestwhole number that equals the average investment yield onstate money for the state's previous fiscal year, excludingpension fund investments, as published in the auditor ofstate's comprehensive annual financial report; and
            (B) accruing from the date that an overpayment iserroneously recovered by the office until the office restoresthe overpayment to the provider.
        (8) Establishing a system with the following conditions:
            (A) Audits may be conducted by the office after service hasbeen provided and before reimbursement for the service hasbeen made.
            (B) Reimbursement for services may be denied if an auditconducted under clause (A) concludes that reimbursementshould be denied.
            (C) Audits may be conducted by the office after service hasbeen provided and after reimbursement has been made.
            (D) Reimbursement for services may be recovered if an auditconducted under clause (C) concludes that the moneyreimbursed should be recovered.
As added by P.L.2-1992, SEC.9. Amended by P.L.278-1993(ss),SEC.28; P.L.42-1995, SEC.23; P.L.107-1996, SEC.10; P.L.8-2005,SEC.2.
IC 12-15-21-4
Rules not to eliminate type of provider licensed to provide services
    Sec. 4. The rules adopted by the secretary may not eliminate atype of provider licensed to provide Medicaid services.
As added by P.L.2-1992, SEC.9.

IC 12-15-21-5
Rules not to be more restrictive than federal Medicaidreimbursement requirements
    Sec. 5. (a) As used in this section, "facility" refers to anintermediate care facility for the mentally retarded (ICF/MR) notoperated by a state agency.
    (b) The rules adopted by the secretary may not establish eligibilitycriteria for Medicaid reimbursement for placement or services in afacility, including services provided under a Medicaid waiver, thatare more restrictive than federal requirements for Medicaidreimbursement in a facility or under a Medicaid waiver.
    (c) The office may not implement a policy that may not beadopted as a rule under subsection (b).
As added by P.L.78-1994, SEC.2. Amended by P.L.272-1999,SEC.41.

IC 12-15-21-6
Amendment of prior authorization rule
    Sec. 6. (a) IC 4-22-2 does not apply to a rulemaking procedureunder this section.
    (b) The office may amend a rule regarding prior authorization (asdefined in 405 IAC 1-6-2) that appears in the Indiana AdministrativeCode on January 1, 1996, to make the prior authorization rule lessrestrictive.
    (c) If the office amends a prior authorization rule under thissection, the office may later amend the prior authorization rule torestore, in whole or in part, the prior authorization rule as it was ineffect on January 1, 1996.
    (d) An amendment to a prior authorization rule under this sectionmust comply with the notice requirements set forth in IC 12-15-13-6.
As added by P.L.107-1996, SEC.11.

IC 12-15-21-6.5
Family practice residency program
    Sec. 6.5. A family practice residency program may choose to havethe name of the residency program, the primary medical provider, orboth, appear on the Medicaid identification card of a recipient whois enrolled in a Medicaid managed care program instead of just thename of the individual primary medical provider in the residencyprogram to whom the recipient has been assigned.
As added by P.L.107-1996, SEC.12 and P.L.257-1996, SEC.11.

IC 12-15-21-7
Rules not to be more stringent than prior authorization rule

effective January 1, 1996
    Sec. 7. The office may not amend a prior authorization rule tomake it more stringent than the prior authorization rule as it was ineffect on January 1, 1996, unless the office changes the rule throughthe rulemaking process.
As added by P.L.107-1996, SEC.13.