Section 405 IAC 1-1.4-12 - Appeal requests; institutional providersAuthority: IC 12-15-21
Affected: IC 4-21.5-3; IC 12-8-6.5-6; IC 12-15-13-4
Sec. 12.
(a) Appeals governed by this rule will be held in accordance with IC 4-21.5-3, except as specifically set out in this rule. The ultimate authority for purposes of this section is the office in accordance with IC 12-8-6.5-6.(b) As used in this section, an "institutional provider" means any Medicaid provider defined in IC 12-15-13-4.(c) Under IC 12-15-13-4, if the office believes that an overpayment to an institutional provider has occurred, the office may: (1) submit a written notice of preliminary draft audit findings of overpayment to the provider; and(2) accept and consider any written comments submitted by the institutional provider regarding the preliminary draft audit and finalize the audit findings and issue a preliminary recalculated Medicaid rate.(d) An institutional provider that receives the preliminary recalculated Medicaid rate under subsection (c)(2) may: (1) request administrative reconsideration of the preliminary audit findings within forty-five (45) calendar days from the date of the notice of recalculated Medicaid rate; or(2) submit a written statement waiving the right to request administrative reconsideration or an appeal and accepting the preliminary calculations as final.(e) If the office believes, after having reviewed an institutional provider's request for reconsideration, that an overpayment occurred, the office shall notify the provider in writing a notice of final calculation of overpayment. An institutional provider may contest the office's final determination by filing an appeal with the office within sixty (60) calendar days from the date of the notice of final calculation.(f) All other appeal requests governed by this rule must be filed with the ultimate authority within fifteen (15) calendar days of receipt of the determination by the office, in accordance with IC 4-21.5-3-7.(g) The deadlines outlined under section 11(f) of this rule shall apply to an appeal filed under this section.(h) An appeal must include the elements listed under section 11(g) of this rule.(i) The institutional provider appealing a final calculation of an overpayment must file with the office a statement of issues:(1) within sixty (60) calendar days after the provider receives notice of the final calculation of overpayment; or(2) at the time the provider files a timely request for appeal; whichever is later.(j) For all other appeal requests, the institutional provider must file with the office a statement of issues: (1) within forty-five (45) calendar days after the provider receives notice of the adverse agency action; or(2) at the time the institutional provider files a timely request for an appeal; whichever is later.(k) The provisions of section 11(j) through 11(o) [of this rule] shall apply to a provider's statement of issues.Office of the Secretary of Family and Social Services; 405 IAC 1-1.4-12; filed 12/21/2018, 3:17 p.m.: 20190116-IR-405180251FRAReadopted filed 5/30/2023, 11:54 a.m.: 20230628-IR-405230292RFA