Sec. 3. The rules adopted under section 2 of this chapter must include the following:
(1) Providing for prior review and approval of medical services.
(2) Specifying the method of determining the amount of reimbursement for services.
(3) Establishing limitations that are consistent with medical necessity concerning the amount, scope, and duration of the services and supplies to be provided. The rules may contain limitations on services that are more restrictive than allowed under a provider's scope of practice (as defined in Indiana law).
(4) Denying payment or instructing the contractor under IC 12-15-30 to deny payment to a provider for services provided to an individual or claimed to be provided to an individual if the office after investigation finds any of the following:
(A) The services claimed cannot be documented by the provider.
(B) The claims were made for services or materials determined by licensed medical staff of the office as not medically reasonable and necessary.
(C) The amount claimed for the services has been or can be paid from other sources.
(D) The services claimed were provided to a person other than the person in whose name the claim is made.
(E) The services claimed were provided to a person who was not eligible for Medicaid.
(F) The claim rises out of an act or practice prohibited by law or by rules of the secretary.
(5) Recovering payment or instructing the contractor under IC 12-15-30-3 to recover payment from a provider for services rendered to an individual or claimed to be rendered to an individual if the office after investigation finds any of the following:
(A) The services paid for cannot be documented by the provider.
(B) The amount paid for such services has been or can be paid from other sources.
(C) The services were provided to a person other than the person in whose name the claim was made and paid.
(D) The services paid for were provided to a person who was not eligible for Medicaid.
(E) The paid claim rises out of an act or practice prohibited by law or by rules of the secretary.
(6) Recovering interest due from a provider:
(A) at a rate that is the percentage rounded to the nearest whole number that equals the average investment yield on state general fund money for the state's previous fiscal year, excluding pension fund investments, as published in the state comptroller's comprehensive annual financial report; and
(B) accruing from the date of overpayment;
on amounts paid to the provider that are in excess of the amount subsequently determined to be due the provider as a result of an audit, a reimbursement cost settlement, or a judicial or an administrative proceeding.
(7) Paying interest to providers:
(A) at a rate that is the percentage rounded to the nearest whole number that equals the average investment yield on state general fund money for the state's previous fiscal year, excluding pension fund investments, as published in the state comptroller's comprehensive annual financial report; and
(B) accruing from the date that an overpayment is erroneously recovered by the office until the office restores the overpayment to the provider.
(8) Establishing a system with the following conditions:
(A) Audits may be conducted by the office after service has been provided and before reimbursement for the service has been made.
(B) Reimbursement for services may be denied if an audit conducted under clause (A) concludes that reimbursement should be denied.
(C) Audits may be conducted by the office after service has been provided and after reimbursement has been made.
(D) Reimbursement for services may be recovered if an audit conducted under clause (C) concludes that the money reimbursed should be recovered.
[Pre-1992 Revision Citation: 12-1-7-15.7(b) part.]
As added by P.L.2-1992, SEC.9. Amended by P.L.278-1993(ss), SEC.28; P.L.42-1995, SEC.23; P.L.107-1996, SEC.10; P.L.8-2005, SEC.2; P.L.113-2014, SEC.35; P.L.9-2024, SEC.332.
