Kan. Admin. Regs. § 129-8-1

Current through Register Vol. 44, No. 2, January 9, 2025

Section 129-8-1 - Applicability; definitions

(a) Applicability. This article of the division's regulations shall apply to grievances, appeals, and state fair hearings involving medical assistance enrollees who are receiving covered services from a managed care entity with a CMS approved contract with the secretary.

(b) Definitions. For purposes of this article of the division's regulations, each of the following terms shall have the meaning specified in this regulation:

(1) "Adequate notice of adverse benefit determination" means a written document that is sent by the MCE to the enrollee or requesting provider at the time the MCE makes an adverse benefit determination and that meets the requirements specified in 129-8-4.

(2) "Adequate notice of appeal resolution" means a written document that is sent by the MCE to the enrollee and requesting provider that includes the MCE's resolution of the enrollee's appeal request and that meets the requirements specified in 129-8-4.

(3) "Adequate notice of approval" means a written document that is sent by the MCE to the enrollee and the requesting provider at the time the MCE approves a covered service authorization request and that meets the requirements specified in 129-8-8.

(4) "Adequate notice of external review decision" means a written document that is sent by the MCE to the enrollee and the provider that includes the external independent third-party reviewer's decision and meets the requirements specified in 129-9-4.

(5) "Adverse benefit determination" means a decision by the MCE for any of the following:

(A) The denial or limited authorization of a requested non-covered service or covered service, including determinations based on the type or level of service, requirements for medical necessity, appropriateness, setting, or effectiveness of a covered service;

(B) the reduction, suspension, or termination of a previously authorized covered service;

(C) the failure to provide covered services in a timely manner, as defined by the secretary;

(D) the failure of the MCE to act within required time frames, which constitutes a denial and an adverse benefit determination and are the following:

(i) The failure to resolve a grievance and send notice within the time frames specified in 129-8-3 ;

(ii) the failure of the MCE to resolve an appeal and send notice within the time frames specified in 129-8-7 ; and

(iii) the failure of the MCE to reach service authorization decisions within the time frames specified in 129-8-4 ;

(E) the denial of the enrollee's request to dispute a financial liability, including cost sharing, copayments, premiums, deductibles, coinsurance, and other enrollee financial liabilities; and

(F) the placement of the enrollee into administrative lock-in due to the enrollee's persistent noncompliance with the requirements of care and treatment, abusive or threatening conduct by the enrollee, fraud or waste by the enrollee, or overuse of covered services, including LTSS, at a frequency or amount that is not medically necessary.

(6) "Appeal" means a review by the MCE of an adverse benefit determination. An appeal is not a local evidentiary hearing, a request to the presiding officer for a state fair hearing, or a grievance.

(7) "Days" means calendar days unless otherwise specified.

(8) "Grievance" means the expression of dissatisfaction to an MCE by the enrollee about any matter other than an adverse benefit determination. This term may include dissatisfaction with the quality of care or services provided, aspects of interpersonal relationships including rudeness of the provider or employee, and failure to respect the enrollee's rights regardless of whether the enrollee requests remedial action. This term shall include the enrollee's right to dispute an extension of time proposed by the MCE to make an authorization decision or resolve an appeal or grievance. An enrollee submitting a grievance shall not have state fair hearing rights.

(9) "Grievance and appeal system" means the grievance, appeal, and state fair hearing processes that are available to enrollees for expressions of dissatisfaction and for contesting adverse benefit determinations regarding covered services and non-covered services, as well as the process by which information is collected and tracked.

(10) "Lock-in" means the MCE's restriction of the enrollee's access to medical services because of the enrollee's abuse of medical services. Lock-in is accomplished through limitation of the use of the MCE's medical identification card to designated medical providers.

(11) "New healthcare service" means a covered service that an MCE has not previously authorized or a covered service that an MCE has previously authorized, but the authorization period for that covered service has expired at the time of the request for additional covered services.

(12) "PCCM" means a primary care case manager, including a physician, a physicians' group practice, or an entity that uses physicians, who provides primary care to the enrollee under a contract with the Kansas medical assistance program.

(13) "Send" means to deliver by U.S. mail or in electronic format.

(14) "Timely notice of adverse benefit determination" means an adequate notice of adverse benefit determination sent by the MCE to the enrollee within the time frames specified in 129-8-4.

(15) "Timely notice of appeal resolution" means an adequate notice of appeal resolution that is sent by the MCE to the enrollee within the time frames specified in 129-8-7.

(16) "Timely notice of approval" means an adequate notice of approval that is sent by the MCE to the enrollee within the time frames specified in 129-8-8.

(17) "Timely notice of external review decision" means an adequate notice of external review decision that is sent by the MCE to the enrollee and requesting provider within the time frame specified in 129-9-4.

Kan. Admin. Regs. § 129-8-1

Authorized by and implementing K.S.A. 65-1,254 and 757403; adopted by Kansas Register Volume 43, No. 50; effective 12/27/2024.