Claims Administrative Review and Appeal
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.
|The claim been denied due to incorrect or inaccurate billing by
||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
|The issue is complicated and involved, or it is obvious that
the provider has made numerous attempts to get the problem
||The provider must submit a Written Inquiry form to HP Written
Correspondence or contact his or her field consultant for
|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
This package of information should be sent to:
HP Written Correspondence
P.O. Box 7263
Indianapolis, IN 46207-7263
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
Indiana Family and Social Services
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.
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