Section 405 IAC 1-1.4-7 - Prepayment reviewAuthority: IC 12-15-1-10; IC 12-15-1-15; IC 12-15-21-2
Affected: IC 4-21.5-3-7; IC 4-21.5-4
Sec. 7.
(a) Prepayment review is a manual claims review process that allows for: (1) review of claims for appropriate coding and documentation; and(2) education on appropriate billing practices.(b) Prepayment review of claims is not a sanction and is not subject to appeal. Providers may be added to or removed from prepayment review at the discretion of the office. Providers released from prepayment review may be subject to future follow-up reviews to ensure continued compliance with the Indiana Administrative Code, any other applicable rules and regulations, and all rules and guidelines set forth in the Indiana Health Coverage Programs (IHCP) provider Reference Modules and all other IHCP publications, including, but not limited to, bulletins and banner pages.(c) The office shall implement prepayment review for a period of six (6) months: (1) The six (6) month period begins upon the first successful adjudication of a claim submission under prepayment review.(2) As part of the prepayment review process, providers are required to send supporting documentation for each claim submission.(3) If the supporting documentation in subdivision (2) is not submitted, the claim shall be denied.(d) During the review period, the office shall conduct a review of the following: (1) Services were provided according to Medicaid policy requirements.(2) The billed services were medically necessary, appropriate, and not in excess of the member's need pursuant to a physician order as documented in policy or services standards.(3) The number of visits and services delivered are logically consistent with the member's characteristics and circumstances, such as type of illness, age, gender, and service location.(4) The provider and member were Medicaid-eligible on the date the service was provided.(5) Prior authorization was obtained if required by policy.(6) The provider's staff was qualified as required by state or federal law.(7) The provider possessed the proper license, certification, or other accreditation requirements specific to the provider's scope of practice and Medicaid policy at the time the service was provided to the member.(8) The claim does not duplicate or conflict with one reviewed previously or currently being reviewed.(9) The payment does not exceed any reimbursement rates or limits in the state plan.(10) Third-party liability within the requirements of 42 CFR 433.137 is appropriately billed and accounted for.(e) On completion of the review period:(1) the office shall review the provider for release from prepayment review if: (A) the provider has achieved an eighty-five percent (85%) or more approval rate on claim submissions for three (3) consecutive months; and(B) the volume of its claim submissions remained within ten percent (10%) of its volume before prepayment review;(2) if the provider successfully completes both requirements under subdivision (1) before the six (6) month deadline, they may be removed from the prepayment review process at the discretion of the office;(3) the provider shall remain on prepayment review for an additional period of six (6) months, and may be required to submit a corrective action plan, if it fails to satisfy either requirement under subdivision (1); and(4) if after the second six (6) month interval prescribed under subdivision (3) the provider fails to satisfy the requirements under subdivision (1), the office may do the following: (A) Deny payment for medical assistance services rendered during a specified period of time.(B) Terminate the provider agreement.(C) Require a corrective action plan.(D) Impose other sanctions as provided in section 4 of this rule.(f) If a provider has been on prepayment review for twelve (12) months the office may terminate the provider agreement if: (1) there has been no billing activity for six (6) consecutive months; or(2) the volume of its claim submissions during the review period was not within ten percent (10%) of its volume before prepayment review.Office of the Secretary of Family and Social Services; 405 IAC 1-1.4-7; filed 12/21/2018, 3:17 p.m.: 20190116-IR-405180251FRAReadopted filed 5/30/2023, 11:54 a.m.: 20230628-IR-405230292RFA