Section 12-16-7.5-2.5 - Segregation of payable claims by fiscal year; division determination of amount of payment(a) Payable claims shall be segregated by state fiscal year.(b) For purposes of this chapter, IC 12-15-15-9, IC 12-15-15-9.5, and IC 12-16-14, "payable claim" refers to the following:(1) Subject to subdivision (2), a claim for payment for physician care, hospital care, or transportation services under this chapter: (A) that includes, on forms prescribed by the division, all the information required for timely payment;(B) that is for a period during which the person is determined to be financially and medically eligible for the hospital care for the indigent program; and(C) for which the payment amounts for the care and services are determined by the division. This subdivision applies for the state fiscal year ending June 30, 2004.
(2) For state fiscal years ending after June 30, 2004, and before July 1, 2007, a claim for payment for physician care, hospital care, or transportation services under this chapter: (A) provided to a person under the hospital care for the indigent program under this article during the person's eligibility under the program;(B) identified in a claim filed with the division; and(C) determined to: (i) have been necessitated by one (1) or more of the medical conditions listed in IC 12-16-3.5-1(a)(1) through IC 12-16-3.5-1(a)(3) or IC 12-16-3.5-2(a)(1) through IC 12-16-3.5-2(a)(3); or(ii) be a direct consequence of one (1) or more of the medical conditions listed in IC 12-16-3.5-1(a)(1) through IC 12-16-3.5-1(a)(3).(3) For state fiscal years beginning after June 30, 2007, a claim for payment for physician care or transportation services under this chapter: (A) provided to a person under the hospital care for the indigent program under this article during the person's eligibility under the program;(B) identified in a claim filed with the division; and(C) determined to: (i) be necessary after the onset of a medical condition that was manifested by symptoms of sufficient severity that the absence of immediate medical attention would probably result in any of the outcomes described in IC 12-16-3.5-1(a)(1) through IC 12-16-3.5-1(a)(3) or IC 12-16-3.5-2(a)(1) through IC 12-16-3.5-2(a)(3); or(ii) be a direct consequence of the onset of a medical condition that was manifested by symptoms of sufficient severity that the absence of immediate medical attention would probably result in any of the outcomes listed in IC 12-16-3.5-1(a)(1) through IC 12-16-3.5-1(a)(3).(c) For purposes of this chapter, IC 12-15-15-9, IC 12-15-15-9.5, and IC 12-16-14, "amount" when used in regard to a claim or payable claim means an amount calculated under STEP THREE of the following formula: STEP ONE: Identify the items and services identified in a claim or payable claim.
STEP TWO: Using the applicable Medicaid fee for service reimbursement rates, calculate the reimbursement amounts for each of the items and services identified in STEP ONE.
STEP THREE: Calculate the sum of the amounts identified in STEP TWO.
(d) For purposes of this chapter, IC 12-15-15-9, IC 12-15-15-9.5, and IC 12-16-14, a provider that submits a claim to the division is considered to have submitted the claim during the state fiscal year during which the amount of the claim was determined under IC 12-16-5.5-1.2(b) or, if successfully appealed by a provider, the state fiscal year in which the appeal was decided.(e) The division shall determine the amount of a claim under IC 12-16-5.5-1.2(b).As added by P.L. 255-2003, SEC.36. Amended by P.L. 145-2005, SEC.24; P.L. 1-2006, SEC.189; P.L. 212-2007, SEC.26; P.L. 218-2007, SEC.37.