405 Ind. Admin. Code 1-1-3.1

Current through October 31, 2024

Section 405 IAC 1-1-3.1 - Providing services to members enrolled under the Medicaid spend-down provision

Authority: IC 12-15-1-10; IC 12-15-21-2

Affected: IC 12-15

Sec. 3.1.

(a) This section applies to a Medicaid-participating provider furnishing services to an individual enrolled in Medicaid under the spend-down provision set out at 405 IAC 2-3-10.

(b) A provider must submit a claim to Medicaid for any service for which Medicaid reimbursement may be available under 405 IAC 5. Such services include services provided in excess of Medicaid benefit limitations. The provider must comply with any prior authorization requirements applicable to the service.

(c) Except for applicable copayments, a provider may not bill a Medicaid member for any part of the provider's charge for a service billed to Medicaid until:

(1) Medicaid has adjudicated the provider's claim for the service; and

(2) the provider has been notified of the portion of the claim that was credited to the Medicaid member's monthly spend-down obligation.

The provider may bill the member for the amount that was credited toward the member's spend-down as well as any unpaid copayment amount due.

(d) A provider may not refuse service to a Medicaid member pending verification that the member's monthly spend-down obligation has been satisfied. A provider may not refuse service to a Medicaid member solely on the basis of the member's spend-down status.

405 IAC 1-1-3.1

Office of the Secretary of Family and Social Services; 405 IAC 1-1-3.1; filed Jul 18, 2005, 1:00 p.m.: 28 IR 3579; readopted filed Sep 19, 2007, 12:16p.m.: 20071010-IR-405070311RFA; readopted filed Oct 28, 2013, 3:18 p.m.: 20131127-IR-405130241RFA

Readopted filed 11/13/2019, 11:54 a.m.: 20191211-IR-405190487RFA

Readopted filed 5/30/2023, 11:54 a.m.: 20230628-IR-405230292RFA