Section 16.05.07.200 - DENIAL OF PAYMENTThe following are reasons the Department may deny payment.
01.Billed Services Not Provided or Not Medically Necessary. The Department may deny payment for any and all claims it determines are for items or services: a. Not provided or not found by the Department to be medically necessary.b. Not documented to be provided or medically necessary.c. Not provided under professionally recognized standards of health care.d. Provided as a result of a prohibited physician referral under 42 CFR Part 411, Subpart J.02.Contrary to Rules or Provider Agreement. The Department may deny payment when services billed are contrary to Department rules or the provider agreement.03.Failure to Provide Immediate Access to Records. The Department may deny payment when the provider does not allow immediate access to records as listed in Section 101 of these rules.Idaho Admin. Code r. 16.05.07.200