KRS § 205.646 — KY Code / Title XVII / Chapter 205 / Section 205.646
205.646 External independent third-party review of Medicaid managed care organization's final decision denying a health care service or a claim for reimbursement -- Submission of multiple claims in a single review -- Appeal -- Administrative regulations -- Applicability of statute
Status: in_force

205.646 External independent third-party review of Medicaid managed care

organization's final decision denying a health care service or a claim for

reimbursement -- Submission of multiple claims in a single review -- Appeal --

Administrative regulations -- Applicability of statute.

(1) As used in this section:

(a) "Administrative appeals hearing" means a formal adjudicatory proceeding

conducted by the Office of Administrative Hearings within the Department of

Law in accordance with KRS Chapter 13B;

(b) "Department" means the Department for Medicaid Services;

(c) "External independent third-party review" means a review performed by an

independent third party outside of the Medicaid managed care organization's

internal appeal process pursuant to administrative regulations promulgated by

the department;

(d) "Medicaid managed care organization" means an entity for which the

Department for Medicaid Services has contracted to serve as a managed care

organization as defined in 42 C.F.R. sec. 438.2; and

(e) "Provider" means any person or entity licensed in Kentucky as defined in

KRS 304.17A-700(9) that provides covered services to enrollees.

(2) Notwithstanding any law to the contrary, a provider who has exhausted the written

internal appeals process of a Medicaid managed care organization shall be entitled

to an external independent third-party review of the Medicaid managed care

organization's final decision that denies, in whole or in part, a health care service to

an enrollee or a claim for reimbursement to a provider for a health care service

rendered by the provider to an enrollee of the Medicaid managed care organization.

A provider may submit multiple claims to be appealed in a single external

independent third-party review if the provider alleges that a Medicaid managed care

organization has implemented a policy or practice that results in the denial, in

whole or in part, of those claims.

(3) A Medicaid managed care organization's letter to a provider reflecting the final

decision of the provider's internal appeal shall include:

(a) A statement that the provider's internal appeal rights within the Medicaid

managed care organization have been exhausted;

(b) A statement that the provider is entitled to an external independent third-party

review; and

(c) The time period and address to request an external independent third-party

review.

(4) A Medicaid managed care organization or provider shall be entitled to appeal a

final decision of the external independent third-party review to the Office of

Administrative Hearings within the Department of Law for an administrative

hearing to be held in accordance with KRS Chapter 13B. An appeal shall be filed

within thirty (30) days from the appealing party's receipt of the final decision of the

external independent third-party review. A decision of the Office of Administrative

Hearings within the Department of Law shall be final for purposes of judicial

appeal. Any appeal of a final decision of an external independent third-party review

involving the submission of multiple claims as allowed under subsection (2) of this

section shall be conducted as a single administrative hearing under this subsection.

(5) The department shall promulgate administrative regulations to implement the

external independent third-party review as required by this section.

(6) The department shall promulgate administrative regulations to establish reasonable

fees, not to exceed one thousand dollars ($1,000), to defray expenses associated

with an administrative hearing that shall be paid by the party who does not prevail

in the administrative hearing. If the administrative hearing is an appeal of a final

decision of an external independent third-party review involving the submission of

multiple claims as allowed under subsection (2) of this section, only one (1) fee

shall be assessed under this subsection against the party who does not prevail.

(7) This section shall apply to all contracts or master agreements between Medicaid

managed care organizations and the Commonwealth of Kentucky entered into or

renewed on or after July 1, 2016.