Authority: 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. 8. (a) The office may deny payment to any provider for Medicaid services rendered, including materials furnished to any individual or claimed to be rendered or furnished to any individual, if, after investigation by the office, the IMFCU, or other governmental authority, the office finds any of the following:

1. (1) The claims were made for services or materials determined by the office, the IMFCU, or other governmental authority as not medically necessary.
2. (2) The amount claimed for such services or materials has been paid from other sources or is subject to third party liability.
3. (3) The services claimed were provided to a person who was not eligible for Medicaid at the time of the provision of the service.

(b) The decision as to denial of payment for a particular claim or claims is at the discretion of the office. This decision shall be final and:

1. (1) shall be mailed to the provider by United States mail at the address contained in the office records and on the claims or transmitted electronically if the provider has elected to receive electronic remittance advices;
2. (2) shall be effective upon receipt; and
3. (3) may be administratively appealed under section 11 of this rule.

(Office of the Secretary of Family and Social Services; 405 IAC 1-1.4-8; filed Dec 21, 2018, 3:17 p.m.: 20190116-IR- 405180251FRA; readopted filed May 30, 2023, 11:54 a.m.: 20230628-IR-405230292RFA)