407 IAC 1-2-2 - Filing of claims; filing date; waiver of limit; claim auditing; payment liability; third party payments
Authority: IC 12-17.6-2-11
Affected: IC 12-17.6
Sec. 2.
(a) The
following claims must be originally filed with the fiscal agent contractor
within twelve (12) months of the date of the provision of service:
(1) All provider claims for payment of
services rendered to CHIP primary care case management members.
(2) All provider claims for payment of
services rendered to CHIP risk-based managed care members if the service is
carved out of a CHIP risk-based MCO contract.
(b) A provider who is dissatisfied with the
disposition of his or her claim by the fiscal agent contractor may request a
payment adjustment or administrative review from the fiscal agent contractor.
Before filing an appeal, the provider must seek administrative review from the
fiscal agent contractor.
(c) All
provider requests for payment adjustments, administrative review, and waiver of
filing limit shall be processed in the same way as such requests are processed
for Medicaid providers under rules promulgated by the secretary at
405 IAC 1-1-3.
(d) All claims filed for reimbursement shall
be reviewed prior to payment by the office or its fiscal contractor, for
completeness, including required documentation, appropriateness of services and
charges, prior authorization when required, and other areas of accuracy and
appropriateness as indicated.
(e) A
provider who contracts with a CHIP risk-based MCO must file its claims with the
risk-based MCO in accordance with the terms of that contract. Such a provider
does not retain any independent right or duplicative right for reimbursement
from the office in addition to or in lieu of the reimbursement that it would
receive from the risk-based MCO. Any disputes about reimbursement shall be
handled in accordance with the terms of the contract between the provider and
the risk-based MCO.
(f) CHIP is
only liable for the payment of claims filed by providers who were certified and
enrolled providers at the time the service was rendered and for services
provided to persons who were enrolled in CHIP at the time service was provided.
Payment may be made for services rendered no earlier than the first day of the
month of CHIP application, if the patient is found to be eligible. Noncertified
and nonenrolled providers giving service during the first month of eligibility
must file a provider application retroactive to the beginning date of eligible
service and meet provider certification requirements during this period. A
claim for services that requires prior authorization provided during the first
month of eligibility will not be paid unless the services have been reviewed
and approved prior to payment. The claim will not be paid if the services
provided are outside the service parameters established by the
office.
(g) No CHIP reimbursement
shall be available for services provided to individuals who are not eligible
CHIP members on the date the service is provided.
(h) No CHIP reimbursement shall be available
for services provided outside the parameters of a restricted health care card
as established in section 1 of this rule.
(i) A CHIP provider shall not collect from a
CHIP member or from the family of a CHIP member any portion of his or her
charge for a CHIP covered service that is not reimbursed by CHIP, except for
any copayment authorized by law. A provider may deny services if the CHIP
member does not pay the copayment, except that a provider may not deny
emergency transportation services.
(j) A CHIP provider may charge a member or
the member's family for a missed appointment if doing so is consistent with the
provider's policy for private pay patients.
Notes
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