Kansas Administrative Regulations › Agency 129 - KANSAS DEPARTMENT OF HEALTH AND ENVIRONMENT-DIVISION OF HEALTH CARE FINANCE › Article 9 - MANAGED CARE PROVIDER GRIEVANCES, RECONSIDERATIONS, APPEALS, EXTERNAL INDEPENDENT THIRD-PARTY REVIEW, AND STATE FAIR HEARINGS; FEEFOR-SERVICE PROVIDER GRIEVANCES AND STATE FAIR HEARINGS › Section 129-9-9 - External independent third-party review for providers

Current through Register Vol. 43, No. 28, July 11, 2024
(a) Effective with
			 each denial issued by a managed care organization (MCO) on or after January 1,
			 2020, each provider who has been denied an authorization for a new healthcare
			 service to an enrollee or a claim for reimbursement to the provider for a
			 healthcare service rendered to an enrollee shall be entitled to an external
			 independent third-party review pursuant to
			 K.S.A.
			 39-709i, and amendments thereto. Each MCO
			 denial reviewed by the external independent third-party reviewer shall have
			 been issued pursuant to a contract between the MCO and the Kansas medical
			 assistance program (KMAP). The contract shall have been effective January 1,
			 2020 or later.
(b) The request for
			 an external independent third-party review shall apply only to denials for
			 which the provider has completed the internal written appeals process of an MCO
			 on or after January 1, 2020. Each provider shall have the right to submit a
			 request for an external independent third-party review following receipt of the
			 MCO's adequate notice of appeal resolution or remittance advice.
(c) The MCO shall send an adequate notice of
			 appeal resolution to the provider when the MCO reviews the request for an
			 appeal of an action or adverse benefit determination. Each adequate notice of
			 appeal resolution shall meet the requirements of the secretary and shall
			 include the following:
(1) The date of the
			 adequate notice of appeal resolution;
(2) the action or adverse benefit
			 determination that is the subject of the appeal;
(3) the results of the resolution process and
			 the date of the appeal resolution;
(4) the reasons for the appeal resolution,
			 including an explanation of the medical basis for the resolution, application
			 of policy, or accepted standard of medical practice to the enrollee's medical
			 circumstances, if the MCO based its resolution upon a determination that the
			 service is not medically necessary;
(5) the statute, regulation, policy, or
			 procedure supporting the appeal resolution;
(6) a statement that the provider has
			 completed the appeal process with the MCO;
(7) a statement of the provider's right to
			 request an external independent third-party review following receipt of the
			 adequate notice of appeal resolution;
(8) a statement of the required procedures by
			 which a provider may request an external independent third-party review with
			 the MCO issuing the decision to be reviewed within 60 days of the date of the
			 adequate notice of appeal resolution. Pursuant to
			 K.S.A.
			 77-531 and amendments thereto, three days
			 shall be added to the 60-day response period if the notice is served by U.S.
			 mail or by electronic means. The statement shall include the address and
			 contact information for submission of the request;
(9) a statement that if the provider does not
			 request an external independent third-party review, the provider has a right,
			 pursuant to
			 K.S.A.
			 39-709h(e)(4) and amendments
			 thereto, to request a state fair hearing within 120 days of the date of the
			 adequate notice of appeal resolution. Pursuant to
			 K.S.A.
			 77-531 and amendments thereto, three days
			 shall be added to the 120-day response period if the notice is served by U.S.
			 mail or by electronic means;
(10)
			 the procedures by which the provider may request a state fair hearing and the
			 address and contact information for submission of the request or, for an action
			 based on a change in law, the circumstances under which a state fair hearing
			 will be granted;
(11) a statement of
			 the provider's right to have self-representation or use legal counsel, a
			 relative, a friend, or a spokesperson; and
(12) any other information required by Kansas
			 statute or regulation that involves the MCO's adequate notice of appeal
			 resolution.