Kentucky Administrative Regulations › Title 907 - CABINET FOR HEALTH AND FAMILY SERVICES - DEPARTMENT FOR MEDICAID SERVICES › Chapter 17 - Managed Care › Section 907 KAR 17:040 - Appeal and administrative hearing post external independent third-party review

Current through Register Vol. 51, No. 1, July 1, 2024
RELATES TO:
				KRS
				194A.025(3),
				205.646, 42 C.F.R. 438
NECESSITY, FUNCTION, AND CONFORMITY: The Cabinet for Health and
				Family Services, Department for Medicaid Services has responsibility to
				administer the Medicaid Program.
				KRS
				205.520(3) authorizes the
				cabinet, by administrative regulation, to comply with a requirement that may be
				imposed or opportunity presented by federal law to qualify for federal Medicaid
				funds. KRS
				205.646 entitles a party to appeal a final
				decision of the external independent third-party review to the administrative
				hearing tribunal within the Cabinet for Health and Family Services. This
				administrative regulation establishes provisions regarding a Medicaid
				provider's and managed care organization's right to an administrative hearing
				following an external independent third-party review.
Section 1. Administrative Hearing Notice and
			 Preliminary Requirements.
(1) Upon the
			 issuance of a final decision by an external independent third-party reviewer
			 pursuant to
			 907 KAR 17:035, the department
			 shall notify in writing the MCO and the provider of the right of the party that
			 received an adverse final decision to appeal the decision by requesting an
			 administrative hearing pursuant to this administrative regulation.
(2)
(a) A
			 written request for an administrative hearing referenced in subsection (1) of
			 this section shall be sent to the department within thirty (30) calendar days
			 of receipt of the department's written notice referenced in subsection (1) of
			 this section.
(b) The request for
			 an administrative hearing shall be sent to the department:
1. Electronically;
2. By fax; or
3. By postal mail.
(3) A provider or MCO request for
			 an administrative hearing shall:
(a) Identify
			 each specific issue and dispute directly related to the adverse final decision
			 issued by the external independent third-party reviewer;
(b) State the basis on which the external
			 independent third-party reviewer's decision on each issue is believed to be
			 erroneous;
(c) Limit disputes to
			 the information contained in the record on appeal, as required by
			 907 KAR 17:035, Section 2(7)(a),
			 and any other information contained in the external independent third-party
			 reviewer's decision;
(d) State the
			 name, mailing address, and telephone number of individuals who may be contacted
			 about the request for an administrative hearing; and
(e) State the mailing address, fax number,
			 email address, or other contact information to which the MCO's confirmation of
			 receipt of the request shall be sent.
(4) The department shall forward to the
			 hearing officer an administrative record on appeal that shall include:
(a) The notice of action taken;
(b) The statutory or regulatory basis for the
			 action taken;
(c) The decision
			 following the external independent third-party review; and
(d) The record on appeal as required by
			 907 KAR 17:035, Section
			 2(7)(a).
(5) The
			 department shall deny a request to initiate the administrative hearing appeal
			 process, or a part thereof, if a party fails to:
(a) Exhaust the external independent
			 third-party review process in accordance with
			 907 KAR 17:035; or
(b) Submit a timely request for
			 administrative hearing in accordance with subsection (2) of this
			 section.