2015 Indiana Code
TITLE 12. HUMAN SERVICES
ARTICLE 15. MEDICAID
CHAPTER 11. PROVIDER AGREEMENTS AND COMPETITIVE BIDDING


Download as PDF IC 12-15-11 Chapter 11. Provider Agreements and Competitive Bidding IC 12-15-11-1 Physician services defined Sec. 1. (a) As used in this chapter, "physician services" means services provided by an individual licensed under IC 25-22.5 while engaged in the practice of medicine (as defined in IC 25-22.5-1-1.1(a)). (b) The term does not include the decision to admit a patient to a hospital. As added by P.L.2-1992, SEC.9. IC 12-15-11-2 Services other than physician services provided by managed care provider; provider agreement; filing; form Sec. 2. A provider desiring to participate in the Medicaid program by providing to individuals eligible for Medicaid services, other than physician services provided by a managed care provider, shall file a provider agreement with the office on forms provided by the office. As added by P.L.2-1992, SEC.9. IC 12-15-11-2.5 Surety bond requirement for certain transportation providers; requirements; revocation or denial of provider agreement for failure to comply; demonstration of compliance; refund Sec. 2.5. (a) As used in this section, "transportation provider" means a person: (1) that is a common carrier, including a person that provides transportation by a taxi; and (2) that: (A) is enrolled; or (B) applies for enrollment; in the Medicaid program as a Medicaid provider to render transportation services to Medicaid recipients. (b) This section does not apply to a transportation provider that is: (1) exempt from federal taxation under Section 501(c)(3) of the Internal Revenue Code; (2) at the discretion of the secretary, granted a waiver of the bond requirement under subsection (c) to provide transportation services in a federal or state designated underserved area; (3) at the discretion of the secretary, granted a waiver of the bond requirement under subsection (c) based on the determination that the provider does not pose a significant risk of submitting fraudulent or false Medicaid claims; (4) owned or controlled by a person that is licensed or certified by an entity described in IC 25-0.5-11; (5) owned or controlled by a pharmacy that has a permit issued under IC 25-26-13; Indiana Code 2015 (6) owned or controlled by a hospital licensed under IC 16-21; or (7) required under federal law to obtain a surety bond to cover Medicaid overpayments and false Medicaid claims and has obtained a bond that complies with the applicable federal law. (c) A transportation provider that applies for enrollment as a Medicaid provider: (1) as a new applicant; (2) due to a change in ownership of a transportation provider currently enrolled; or (3) due to a purchase or transfer of the assets of a transportation provider currently enrolled; shall, at the time the transportation provider files a provider agreement with the office, submit to the office a surety bond that meets the requirements of subsection (d) and is issued by a surety that is authorized by the office of the secretary. (d) The following apply to a surety bond filed with the office under this section: (1) The surety bond must be continuously in effect for at least three (3) years after the application is made as described in subsection (c). (2) The surety bond must provide coverage for liability of at least fifty thousand dollars ($50,000). (3) The surety bond must name the: (A) transportation provider as the principal; (B) office as the obligee; and (C) person that issues the surety bond, including the person's heirs, executors, administrators, successors, and assignees, jointly and severally, as surety. (4) The surety bond must provide the surety's name, street address or post office box number, city, state, and ZIP code. (5) The surety bond must provide that the surety is liable under the surety bond for a duplicate, erroneous, or false Medicaid claim paid by the office or its fiscal agent to the transportation provider during the term of the surety bond. (6) The surety bond must provide that the bond may not be void on a first recovery, but that suits may be instituted until the penalty is exhausted. (7) The surety bond must guarantee that the surety will, not later than thirty (30) days after the surety receives written notice from the office containing sufficient evidence to establish the surety's liability under the surety bond as described in subdivision (5), pay to the office the following amounts, not to exceed the full amount of the surety bond: (A) The amount of the duplicate, erroneous, or false claim that was previously paid by the office or its fiscal agent to the transportation provider, plus accrued interest. (B) An assessment imposed under IC 12-15-22 by the office on the transportation provider. Indiana Code 2015 (8) The surety bond must provide that if the transportation provider's provider agreement is not renewed or is terminated, the surety bond submitted by the transportation provider remains in effect until the last day of the surety bond coverage period and the surety remains liable for a duplicate, erroneous, or false claim paid by the office or its fiscal agent to the transportation provider during the term of the surety bond. (9) The surety bond must provide that actions under the surety bond may be brought by the office or the attorney general. (e) The office may revoke or deny a provider agreement for a transportation provider's failure to comply with this section. (f) The office may revoke a provider agreement if a transportation provider cancels a surety bond required by this section. (g) The office or its designee may, at any time, require a transportation provider to demonstrate compliance with this section. (h) If: (1) a surety has paid the office for a liability incurred under a surety bond under this section; and (2) the transportation provider is subsequently successful in appealing the determination of liability; the office shall, upon completion of the appellate process, refund the surety or the transportation provider the full amount paid for the liability. As added by P.L.197-2013, SEC.11. Amended by P.L.3-2014, SEC.4. IC 12-15-11-3 Provider agreement requirements Sec. 3. A provider agreement must do the following: (1) Include information that the office determines necessary to facilitate carrying out of IC 12-15. (2) Prohibit the provider from requiring payment from a recipient of Medicaid, except where a copayment is required by law. (3) For providers categorized as high risk to the Medicaid program under 42 U.S.C. 1395cc(j)(2)(B) and 42 CFR 455.450, require the submission of necessary information, forms, or consents for the office to obtain a national criminal history background check through the state police department under IC 10-13-3-39 of any person who: (A) holds at least a five percent (5%) ownership interest in a facility or entity; or (B) is a member of the board of directors of a nonprofit facility or entity; in which the provider applicant plans to provide Medicaid services under the provider agreement. The provider applicant is responsible for the cost of the national criminal history background check. As added by P.L.2-1992, SEC.9. Amended by P.L.197-2013, SEC.12. Indiana Code 2015 IC 12-15-11-4 Provider agreement to provide physician services; site visit for moderate or high categorical risk designees Sec. 4. (a) A provider desiring to participate in the Medicaid program by providing physician services as a managed care provider must enter into a provider agreement with the office or the contractor under IC 12-15-30 to provide Medicaid services. (b) Before the office may approve a provider agreement, the office shall conduct a pre-enrollment site visit for provider applicants that are designated as moderate or high categorical risks to the Medicaid program under 42 U.S.C. 1395cc(j)(2)(B) and 42 CFR 455.450. As added by P.L.2-1992, SEC.9. Amended by P.L.197-2013, SEC.13. IC 12-15-11-5 Compliance with enrollment requirements Sec. 5. A provider who participates in the Medicaid program must comply with the enrollment requirements that are established under rules adopted under IC 4-22-2 by the secretary. As added by P.L.2-1992, SEC.9. IC 12-15-11-6 Execution of provider agreement; authority of office to exclude provider from participation by entry into exclusive contract with another provider Sec. 6. After a provider signs a provider agreement under this chapter, the office may not exclude the provider from participating in the Medicaid program by entering into an exclusive contract with another provider or group of providers, except as provided under section 7 of this chapter. As added by P.L.2-1992, SEC.9. IC 12-15-11-7 Competitive bids; services and items for which bids may be sought Sec. 7. The office may seek competitive bids for the following items or services provided under Medicaid: (1) Prescribed drugs and services for state operated institutions. (2) Physical therapy and other therapeutic services. (3) Prescribed laboratory and x-ray services. (4) Eyeglasses and prosthetic devices. (5) Medical equipment and supplies. (6) Transportation services. As added by P.L.2-1992, SEC.9. IC 12-15-11-8 Use of provider identification number; prohibition on limiting claims for primary care services Effective 1-1-2016. Sec. 8. (a) A community mental health center may use the center's provider identification number to file any Medicaid claim, including Indiana Code 2015 primary care health services, if the community mental health center: (1) is otherwise treating the individual for a mental health condition or an addictive disorder; and (2) meets the requirements to provide the services rendered. (b) The office may not require a community mental health center to obtain a separate provider identification number to provide services that the community mental health center meets the requirements to provide. (c) The office may not limit the filing of a Medicaid claim by a community mental health center for primary care services, mental health conditions, and addictive disorders on the same day as long as the claim is filed in accordance with the rules set forth by the office and the services are covered services and necessary to ensure coordinated care for the recipient. As added by P.L.185-2015, SEC.12. Indiana Code 2015

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