405 Ind. Admin. Code 14-4-14

Current through October 9, 2024

Section 405 IAC 14-4-14 - Claims processing and reimbursement

Authority: IC 12-15-1-10

Affected: IC 12-15-12; IC 12-15-13; IC 12-15-21-3; IC 27-13-36.2-3

Sec. 14.

(a) The MCO shall reimburse providers for covered medically necessary services rendered to the MCO's members under the claims processing and confidentiality standards set forth in IC 12-15-13-1.5, IC 12-15-13-1.6, and IC 12-15-13-1.7, unless the MCO and provider agree to an alternate payment schedule and method.

(b) The MCO shall process claims from providers under 42 CFR 447.45(d)(5) and 42 CFR 447.45(d)(6), which require the MCO to ensure the receipt date is the date the MCO receives the claim, as indicated by the date stamp on the claim, while the payment date is the date of the check or other form of payment.

(c) The MCO shall pay or deny a clean claim, as defined at 405 IAC 14-2-10, within:

(1) twenty-one (21) calendar days after receiving an electronically filed clean claim; and

(2) thirty (30) calendar days after receiving paper claims.

(d) If the MCO fails to pay or deny a clean claim, irrespective of whether the provider submitting the claim is contracted with the MCO, within the time frames in subsection (c) and later reimburses for any services itemized in the claim, the MCO shall also pay the provider interest at the rate set forth in IC 12-15-21-3 (7)(A). This interest is paid on clean claims paid late that the MCO is responsible for, unless the MCO and provider have made alternate written payment arrangements.

(e) The MCO shall reject or deny unclean claims within one (1) year after receiving the claims.

(f) The MCO shall meet the requirements and provider notification of claim deficiencies timelines set forth in IC 27-13-36.2-3.

(g) The time limit for submitting claims to the MCO are as follows:

(1) one hundred eighty (180) days after the service date for claims submitted by a provider not contracted with the MCO; and

(2) generally ninety (90) calendar days after the service date for claims submitted by a provider contracted with the MCO, with the filing limit further established in the MCO's contract with the office.

(h) The timely filing limits in subsection (g) are automatically waived by the MCO in certain instances that include:

(1) office error;

(2) eligibility changes, including retroactivity; or

(3) any other condition established by the office.

405 IAC 14-4-14

Office of the Secretary of Family and Social Services; 405 IAC 14-4-14; filed 8/30/2024, 11:42 a.m.: 20240925-IR-405240180FRA