Claims Administrative Review and Appeal

If a provider disagrees with the Indiana Health Coverage Programs (IHCP) determination of payment, the provider's right of recourse is to file an administrative review and appeal, as provided for in Indiana Administrative Code 405 IAC 1 1 3.

Administrative reviews related to nonpharmacy claims reimbursed under the fee-for-service (FFS) delivery system (such as claims for Traditional Medicaid members) are the responsibility of the IHCP fiscal agent. For more information about administrative review for FFS claims, see the Claim Administrative Review and Appeals provider reference module.

To make inquiry or to file for an administrative review of a FFS claim payment determination, providers should use the Indiana Health Coverage Programs Written Inquiry Form or the Indiana Health Coverage Programs Administrative Review Request, available on the Forms page on this site.

Pharmacy claims reimbursed under the FFS delivery system are the responsibility of OptumRX. Contact the OptumRX helpdesk for more information.

Administrative reviews related to claims for members enrolled in Hoosier Healthwise, Hoosier Care Connect, or Healthy Indiana Plan (HIP) are the responsibility of the managed care entity (MCE) with which the member was enrolled at the time of service. The exception is for services carved out of managed care and processed under the FFS delivery system. Administrative reviews related to claims for carved-out services follow the FFS administrative review guidelines.

Each MCE that participates in an IHCP managed care program is required to have a formal procedure for providers requesting reconsideration of claim determinations made by the MCE. For specific information related to the MCE process, contact the MCE directly.

Providers may direct appeals for FFS claim administrative review determinations to the Indiana Family and Social Services Administration (FSSA). The appeals process is described in the reference documents previously mentioned.