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Structured Family Caregiving Billing and Claim Restrictions Applied to TBI and MFP (BT2024183)

Indianasub_regulatoryIndiana Health Coverage Programs (IHCP)· effective 2024-12-18

What this rule requires your agency to do

  • 1Effective Dec. 18, 2024, providers billing Structured Family Caregiving for DOS on or after July 1, 2024 must submit a claim note with the caregiver's name and relationship to the member (or the claim is denied with EOB 4405).(Structured Family Caregiving Billing and Claim Restrictions Applied to TBI and MFP (BT2024183))
  • 2Attendant Care (S5125 U7 combinations) is not payable in the same calendar month as Structured Family Caregiving; if both are billed, only SFC is paid and paid Attendant Care claims are recouped (EOB 6492).(Structured Family Caregiving Billing and Claim Restrictions Applied to TBI and MFP (BT2024183))
  • 3The claim note relationship (REL) must use exactly one of: Parent of minor child; Spouse; Other (no other wording allowed).(Structured Family Caregiving Billing and Claim Restrictions Applied to TBI and MFP (BT2024183))
  • 4Home and Community Assistance (S5130 U7 combinations) is not payable in the same calendar month as Structured Family Caregiving; if both are billed, only SFC is paid and paid HCA claims are recouped (EOB 6492).(Structured Family Caregiving Billing and Claim Restrictions Applied to TBI and MFP (BT2024183))
  • 5Where multiple caregivers provide SFC in the same day, if one is a legally responsible individual (LRI), the provider must supply the LRI's information in the claim note; if none is an LRI, supply the information for the individual who provided care first.(Structured Family Caregiving Billing and Claim Restrictions Applied to TBI and MFP (BT2024183))

Applies to: personal care

Requires SFC claim notes identifying the caregiver's name and relationship and bars billing Attendant Care or Home and Community Assistance in the same calendar month as SFC, with recoupment for overlapping claims.

Regulatory information, not legal advice — always confirm against the cited official source. Verification reduces error; it does not certify compliance.