Ind. Admin. Code tit. 405, r. 10-9-3 – Provision of covered services; verification of enrollment

Sec. 3. (a) Except as provided in subsection (b), before providing any nonemergency service covered under the plan, a provider shall verify all of the following:

(1) The individual is eligible for the plan.
(2) The individual is enrolled with a managed care organization.
(3) The individual is enrolled in the plan at the time the service is being provided.
(4) The individual whose name appears on the card is the same individual for whom the service is being performed.
(5) The service is covered under the member's benefit plan.

Failure to do so may result in denial of the provider's claim if the individual is not enrolled in the plan or the service is not authorized.

(b) Hospitals providing services to individuals during the presumptive eligibility period in accordance with 405 IAC 10-4-11(c), 405 IAC 10-4-11(d), or 405 IAC 10-4-11(e) shall be exempt from the requirements of subsection (a)(1) and (a)(2). Such hospitals shall verify that the individual is eligible for presumptive eligibility under 405 IAC 10-4-11.

(c) If an individual is disenrolled from a managed care organization while receiving inpatient hospital services covered under the plan, the managed care organization shall pay any claims related to the covered inpatient hospital services provided to the member through the date of discharge.

(Office of the Secretary of Family and Social Services; 405 IAC 10-9-3; filed May 18, 2015, 12:34 p.m.: 20150617-IR-405140339FRA; filed Jan 19, 2018, 8:42 a.m.: 20180214-IR-405170484FRA; readopted filed Oct 16, 2024, 11:20 a.m.: 20241113-IR-405230817RFA)