Section 407 IAC 1-2-2 - Filing of claims; filing date; waiver of limit; claim auditing; payment liability; third party paymentsAuthority: IC 12-17.6-2-11
Affected: IC 12-17.6
Sec. 2.
(a) The following claims must be originally filed with the fiscal agent contractor within twelve (12) months of the date of the provision of service: (1) All provider claims for payment of services rendered to CHIP primary care case management members.(2) All provider claims for payment of services rendered to CHIP risk-based managed care members if the service is carved out of a CHIP risk-based MCO contract.(b) A provider who is dissatisfied with the disposition of his or her claim by the fiscal agent contractor may request a payment adjustment or administrative review from the fiscal agent contractor. Before filing an appeal, the provider must seek administrative review from the fiscal agent contractor.(c) All provider requests for payment adjustments, administrative review, and waiver of filing limit shall be processed in the same way as such requests are processed for Medicaid providers under rules promulgated by the secretary at 405 IAC 1-1-3.(d) All claims filed for reimbursement shall be reviewed prior to payment by the office or its fiscal contractor, for completeness, including required documentation, appropriateness of services and charges, prior authorization when required, and other areas of accuracy and appropriateness as indicated.(e) A provider who contracts with a CHIP risk-based MCO must file its claims with the risk-based MCO in accordance with the terms of that contract. Such a provider does not retain any independent right or duplicative right for reimbursement from the office in addition to or in lieu of the reimbursement that it would receive from the risk-based MCO. Any disputes about reimbursement shall be handled in accordance with the terms of the contract between the provider and the risk-based MCO.(f) CHIP is only liable for the payment of claims filed by providers who were certified and enrolled providers at the time the service was rendered and for services provided to persons who were enrolled in CHIP at the time service was provided. Payment may be made for services rendered no earlier than the first day of the month of CHIP application, if the patient is found to be eligible. Noncertified and nonenrolled providers giving service during the first month of eligibility must file a provider application retroactive to the beginning date of eligible service and meet provider certification requirements during this period. A claim for services that requires prior authorization provided during the first month of eligibility will not be paid unless the services have been reviewed and approved prior to payment. The claim will not be paid if the services provided are outside the service parameters established by the office.(g) No CHIP reimbursement shall be available for services provided to individuals who are not eligible CHIP members on the date the service is provided.(h) No CHIP reimbursement shall be available for services provided outside the parameters of a restricted health care card as established in section 1 of this rule.(i) A CHIP provider shall not collect from a CHIP member or from the family of a CHIP member any portion of his or her charge for a CHIP covered service that is not reimbursed by CHIP, except for any copayment authorized by law. A provider may deny services if the CHIP member does not pay the copayment, except that a provider may not deny emergency transportation services.(j) A CHIP provider may charge a member or the member's family for a missed appointment if doing so is consistent with the provider's policy for private pay patients.Office of the Children's Health Insurance Program; 407 IAC 1-2-2; filed May 3, 2000, 2:02 p.m.: 23 IR 2227; readopted filed May 22, 2006, 3:22 p.m.: 29 IR 3424; filed Jun 1, 2011, 2:28 p.m.: 20110629-IR-407100420FRA; readopted filed Jun 18, 2012, 11:23 a.m.: 20120718-IR-407120202RFA