405 IAC 1-1.6-1 Scope

Sec. 1. (a) This rule applies to disputes relating to claims submitted to risk-based managed care organizations (MCOs) contracted with the office by providers who are not contracted with the MCO and who provide services to a Medicaid member enrolled in a risk-based managed care plan. (b) This rule governs the procedures for a provider's objection to a determination by the MCO involving the provider's claim, including a provider's objection to: (1) any determination by the MCO regarding payment for a claim submitted by the provider, including the amount of such payment; or (2) the MCO's determination that a claim submitted by the provider lacks sufficient supporting information, records, or other materials. (c) The procedures in this rule may, at the election of a provider, be utilized to determine the payment due for a claim in the event the MCO fails, within thirty (30) days after the provider submits the claim, to notify the provider of its determination: (1) regarding payment for the provider's claim; or (2) that the provider's claim lacked sufficient supporting information, records, or other materials.