Section 405 IAC 14-6-16 - Claims processing and reimbursementAuthority: 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. 16.
(a) For the first five (5) years the PathWays program is in operation, the following providers contracted with the office are reimbursed by an MCO at a rate not less than the FFS rate for the same service, regardless of whether the provider is contracted with the MCO:(1) Skilled nursing facilities.(2) Home health providers.(b) The MCO shall reimburse providers not contracted with the MCO at the rates specified in section 15(d) of this rule.(c) The MCO shall reimburse providers for covered medically necessary services given 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.(d) 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.(e) The MCO shall pay or deny a clean claim, as defined at 405 IAC 14-2-10, within the following: (1) Electronically filed clean claims within twenty-one (21) calendar days after receiving a claim.(2) Paper claims within thirty (30) calendar days after receiving a claim.(f) 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 described in subsection (e) 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, unless the MCO and provider have made alternate written payment arrangements.(g) The MCO shall reject or deny unclean claims within thirty (30) days after receiving a claim.(h) The MCO shall meet the requirements and provider notification of claim deficiencies timelines set forth in IC 27-13-36.2-3.(i) The time limit for submitting claims to the MCO are as follows: (1) Six (6) months after the date of service for claims submitted by a provider not contracted with the MCO.(2) Generally ninety (90) calendar days after the date of service for claims submitted by a provider contracted with the MCO, with the filing limit further established in the MCO's contract with the office.(j) The timely filing limits in subsection (i) are automatically waived by the MCO in certain instances, which include:(2) eligibility changes, including retroactivity; or(3) any other condition established by the office.Office of the Secretary of Family and Social Services; 405 IAC 14-6-16; filed 8/30/2024, 11:42 a.m.: 20240925-IR-405240180FRA