405 IAC 1-1.4-10 Provider payments during pendency of applicant or member appeals; recovery

Sec. 10. (a) The office may recover payment from any provider listed in subsection (c) for services rendered to an individual if such services are determined to have been not medically necessary or not reasonable or otherwise inappropriate. Recovery of payments may be made as follows: (1) When the office is required by 42 CFR 431.230(a) to maintain services to a member during the pendency of an appeal, and the hearing decision is favorable to the office. (2) When the office has been required, under 42 CFR 431.246, to make corrective payments following an evidentiary hearing decision favorable to the appellant, and the secretary or the secretary's designee thereafter renders a decision favorable to the office at administrative review. (b) The office may recoup under subsection (a) when the appeal has been voluntarily dismissed by the appellant. (c) Services for which the office may recover payment under subsection (a) are limited to those rendered by any of the following providers: (1) Inpatient hospital facilities. (2) Nursing facilities. (3) CRFs/DD. (4) ICFs/IID. (d) Interest shall be assessed on amounts recouped under this section and shall accrue from the date of the overpayment. Such interest charge shall be determined under IC 12-15-13-3.5(g) for a noninstitutional provider or IC 12-15-13-4(h) for an institutional provider.