Section 405 IAC 1-1.4-11 - Appeal requests; noninstitutional providersAuthority: IC 12-15-21
Affected: IC 4-21.5-3; IC 12-8-6.5-6; IC 12-15-13-3.5
Sec. 11.
(a) Appeals governed by this rule will be held in accordance with IC 4-21.5-3, except as specifically set out in this rule. In accordance with IC 12-8-6.5-6, the office is the ultimate authority for purposes of this section.(b) As used in this section, a "noninstitutional provider" means any Medicaid provider defined in IC 12-15-13-3.5.(c) Under IC 12-15-13-3.5, if the office believes that an overpayment to a noninstitutional provider has occurred, the office may submit a written notice of preliminary draft audit finding of overpayment to the provider. A noninstitutional provider that receives the preliminary audit findings may: (1) request administrative reconsideration of the preliminary audit findings within forty-five (45) calendar days from the date of the notice of preliminary findings, along with all comments and additional documentation to support the request; or(2) submit a written statement waiving the right to request administrative reconsideration or an appeal and accepting the preliminary calculations as final.(d) If the office determines, after having reviewed a noninstitutional provider's timely request for reconsideration, that an overpayment occurred, the office shall notify the provider in writing of the final calculation of overpayment. A noninstitutional provider may contest the office's determination by filing an appeal with the office within sixty (60) calendar days from the date of the notice of final calculation of overpayment.(e) The noninstitutional provider appealing a final calculation of an overpayment must file with the office a statement of issues: (1) within sixty (60) calendar days after the provider receives notice of the final calculation of overpayment; or(2) at the time the provider files a timely request for appeal; whichever is later.(f) All other appeal requests governed by this rule must be filed with the ultimate authority within fifteen (15) calendar days of receipt of the determination by the office, in accordance with IC 4-21.5-3-7.(g) For all other appeal requests, the noninstitutional provider must file with the office a statement of issues: (1) within forty-five (45) calendar days after the provider receives notice of the adverse agency action; or(2) at the time the noninstitutional provider files a timely request for an appeal; whichever is later.(h) If a deadline for filing under this section is a:(4) day the office in which the act is to be done is closed during regular business hours; the filing must be received by the office by close of business the next business day. A filing received after close of business on date of the deadline is invalid and will result in the waiver of any right to appeal the office's determination. For purposes of this subsection, "close of business" means 5:00 p.m., local time, on the business day where the filing is received.(i) An appeal filed under this section must state facts demonstrating that the petitioner is: (1) a person to whom the order is specifically directed;(2) aggrieved or adversely affected by the order; or(3) entitled to review under any law.(j) The statement of issues shall set out in detail:(1) the specific findings, action, or determinations of the office from which the provider is appealing; and(2) with respect to each finding, action, or determination: (A) why the provider believes that the office's determination was in error; and(B) all statutes or rules supporting the provider's contentions of error.(k) The statement of issues shall govern the scope of the issues to be adjudicated in the appeal under this rule. The provider will not be permitted to expand the appeal beyond the statement of issues with respect to the:(1) specific findings, action, or determination of the office; or(2) reason or rationale supporting the provider's appeal.(l) The provider may supplement or modify its statement of issues for good cause shown, up to sixty (60) calendar days after the appeal request is mailed to the office. The administrative law judge assigned to hear the appeal will determine good cause.(m) Within thirty (30) days after filing a petition for review, and upon a finding of good cause by the administrative law judge, a hospital appealing an action described in IC 4-21.5-3-6(a)(3) and IC 4-21.5-3-6(a)(4) may amend the statement of issues contained in a petition for review to add one (1) or more additional issues.(n) Failure of the provider to timely file a statement of issues within the timelines provided in subsections (e) and (g) will result in automatic certification to the secretary for summary review, in accordance with section 13 of this rule.(o) Notwithstanding subsections (h) through (k), a hospital provider that files an appeal after a determination regarding year-end cost settlement may preserve any Medicaid issues that are affected by any Medicare appeal issues, by indicating in its statement of issues that Medicare issues timely filed before the fiscal intermediary are also preserved in its Medicaid statement of issues.Office of the Secretary of Family and Social Services; 405 IAC 1-1.4-11; filed 12/21/2018, 3:17 p.m.: 20190116-IR-405180251FRAReadopted filed 5/30/2023, 11:54 a.m.: 20230628-IR-405230292RFA