Claims Administrative Review and Appeal

Overview

Claims Administrative Review and Claims Appeal are distinct processes, each having its own criteria and procedures.

Generally, a Claims Administrative Review does not begin until all routine claims processing measures have been exhausted, and a Claims Appeal cannot be filed until a Claims Administrative Review has been completed.

Before requesting a formal Administrative Review, providers must exhaust the routine measures below.

Routine Measures

Situation Next step
The claim been denied due to incorrect or inaccurate billing by the provider. The provider must make applicable corrections and resubmit the claim via routine channels.
The claim has been paid, but the provider disagrees with the amount of the reimbursement. The provider must submit an adjustment request with documentation stating why he or she disagrees with the reimbursement.
The issue is complicated and involved, or it is obvious that the provider has made numerous attempts to get the problem solved. The provider must submit a Written Inquiry form to HP Written Correspondence or contact his or her field consultant for review.
The provider has submitted a corrected claim or an adjustment request, but received the same determination of payment. The provider must submit a Written Inquiry form stating why he or she disagrees with the denial or amount of reimbursement, note "Administrative Review" clearly on the form, and attach all pertinent documentation.

This package of information should be sent to:

HP Written Correspondence
Administrative Review
P.O. Box 7263
Indianapolis, IN 46207-7263

Claims Appeal

When, pursuant to 405 IAC 1-1-3, all procedures required for administrative review prior to the filing of an appeal have been exhausted, a provider may send a request for an appeal to:

Indiana Family and Social Services Administration
Hearings and Appeals Section, MS-04
402 W. Washington St., Room W392
Indianapolis, IN 46204-2773

Refer to 405 IAC 1-1-5.1 for appeal procedures.

Appeal sequence and applicable time limits

  • An appeal request must be delivered to the Indiana Family and Social Services Administration (IFSSA) within 15 days after receipt of an adverse Administrative Review decision notice on which the appeal is premised.
  • An administrative law judge's adverse decision can be appealed by filing objections with the ultimate authority for the agency within 15 days of receipt of the decision.
  • An appellant can file a petition for judicial review in accordance with IC 4-21.5-5 if the appellant is not satisfied with the agency review decision.

For More Information