Authority: IC 12-15-1-10; IC 12-15-21-3

Affected: IC 4-21.5-3-2; IC 12-13-7-3; IC 12-15-13-4

Sec. 13. (a) A reconsideration request shall be in writing, and contain specific issues to be considered and the rationale for the provider's position. The provider shall timely request administrative reconsideration before filing an appeal. The events detailed in subdivisions (1) through (4) shall be communicated to nursing facilities through a formal letter, either through United States mail or a secure web portal, which begins the period for a timely request. The events are as follows:

1. (1) Schedule of adjustments or a summary of findings resulting from a review performed under section 4 of this rule.
2. (2) CMI quarterly or biannual updates, or a recalculation of CMIs due to an MDS review.
3. (3) The parameters used to calculate an issued rate other than the schedule of adjustments in subdivision (1) and CMIs in subdivision (2).
4. (4) Rate reductions or corrective remedies under section 12 of this rule.

The request shall be signed by the provider or authorized representative of the provider, and shall be received by the office not later than fifteen (15) days after the date of issuance. The office shall evaluate the reconsideration request and may affirm or amend the original decision. The office shall thereafter notify the provider of its final decision in writing not later than forty-five (45) days after the office's receipt of the request for reconsideration. If a timely response is not made by the office to the provider's reconsideration request, the request shall be considered denied and the provider may pursue its administrative remedies under subsection (c).

(b) Under IC 4-21.5-3-2(e), for a notification letter served through United States mail, the fifteen (15) day reconsideration period begins three (3) days after the date of the notification letter.

(c) After completion of the reconsideration procedure under subsection (a), the provider may initiate an appeal under IC 4-21.5-3. The request for an appeal shall be signed by the nursing facility provider. Only issues raised by the provider through administrative reconsideration may be later raised in an appeal.

(d) The office may take action to implement changes made under subsection (a) before the outcome of an appeal filed under subsection (c).

(e) The office may implement Medicaid rates and recover overpayments from previous rate reimbursements, either through deductions of future payments or otherwise, before the outcome of the administrative appeal process as prescribed by IC 12-15-13-4(e).

(Office of the Secretary of Family and Social Services; 405 IAC 1-14.7-13; filed Aug 20, 2024, 9:11 a.m.: 20240918-IR-405240088FRA)