Kan. Admin. Regs. § 129-8-11

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

Section 129-8-11 - Request for state fair hearing; timeliness

(a) For each request for a standard state fair hearing under this article of the division's regulations to be considered timely, the request shall be received by the MCE or the secretary's designee for the state fair hearing according to the following time frames:

(1) For each standard state fair hearing request by the enrollee involving the MCE's adverse benefit determination, the request shall be received by the MCE or the secretary's designee for the state fair hearing within 120 days from the date of the adequate notice of appeal resolution. If the 120^th day falls on a non-business day for the state, the time period for receipt of a request for a state fair hearing shall be extended to the next business day on which the department is open for business. Three days shall be added to the 120-day response period if the notice is served by U.S. mail or electronic means. If the third day falls on a non-business day for the state, the time period shall be extended to the next business day on which the department is open for business.

(2) For each standard state fair hearing request by the enrollee involving the MCE's denial of an authorization for a new healthcare service that was reviewed by the external independent third-party reviewer, the request shall be received by the MCE or the secretary's designee for the state fair hearing within 30 days from the date of the MCE's adequate notice of external review decision pursuant to K.S.A. 39-709i, and amendments thereto. If the 30^th day falls on a non-business day for the state, the time period for receipt of a request for a state fair hearing shall be extended to the next business day on which the department is open for business. Three days shall be added to the 30-day response period if the notice is served by U.S. mail or electronic means. If the third day falls on a non-business day for the state, the time period shall be extended to the next business day on which the department is open for business.

(3) For each standard state fair hearing request by the enrollee involving the enrollee's request to disenroll from the enrollee's MCE, the request shall be received by the secretary or the secretary's designee for the state fair hearing within 30 days from the date of the secretary's adequate notice of action. If the 30^th day falls on a non-business day for the state, the time period for receipt of a request for a state fair hearing shall be extended to the next business day on which the department is open for business. Three days shall be added to the 30-day response period if the notice is served by U.S. mail or electronic means. If the third day falls on a non-business day for the state, the time period shall be extended to the next business day on which the department is open for business.

(4) The presiding officer shall issue an initial order in a standard state fair hearing within 90 days from the date the presiding officer receives a request for a state fair hearing, except when the request for a state fair hearing involves the issue being reviewed by the external independent third-party reviewer or when the presiding officer allows an extension.

(b) For each request for an expedited state fair hearing under this article of the division's regulations to be considered timely, the request shall be received by the MCE or the secretary's designee for the state fair hearing according to the following time frames:

(1) For each request for an expedited state fair hearing involving the MCE's adverse benefit determination, the request shall be received by the MCE or the secretary's designee for the state fair hearing within 120 days from the date of the written adequate notice of appeal resolution. If the 120^th day falls on a non-business day for the state, the time period for receipt of a request for an expedited state fair hearing shall be extended to the next business day on which the department is open for business. Three days shall be added to the 120-day response period if the notice is served by U.S. mail or electronic means. If the third day falls on a non-business day for the state, the time period shall be extended to the next business day on which the department is open for business.

(2) For each expedited state fair hearing request by the enrollee involving the MCE's denial of an authorization for a new healthcare service that was reviewed by the external independent third-party reviewer, the request shall be received by the MCE or the secretary's designee for the state fair hearing within 30 days from the date of the MCE's adequate notice of external review decision pursuant to K.S.A. 39-709i, and amendments thereto. If the 30^th day falls on a non-business day for the state, the time period for receipt of a request for an expedited state fair hearing shall be extended to the next business day on which the department is open for business. Three days shall be added to the 30-day response period if the notice is served by U.S. mail or electronic means. If the third day falls on a non-business day for the state, the time period shall be extended to the next business day on which the department is open for business.

(3) Any enrollee may request an expedited state fair hearing following any appeal of a denial of a service that, as indicated by the MCE, meets the criteria for expedited resolution of the appeal but was not resolved within the time frame for expedited resolution of the appeal by the MCE or was resolved within the time frame for expedited resolution of the appeal, but the MCE reached a decision wholly or partially adverse to the enrollee.

(4) The presiding officer shall schedule the expedited state fair hearing and issue an initial order as expeditiously as the enrollee's health condition requires, but no later than three business days after the presiding officer receives from the MCE the case file and information for any request that meets the criteria specified in subsection (b).

(c) Any enrollee may submit an oral or written request for a standard or expedited state fair hearing with the MCE. Any enrollee may submit a written request for a standard or expedited state fair hearing with the secretary's designee for the state fair hearing. Oral, telephonic, or electronic requests for a standard or an expedited state fair hearing may not be submitted to the secretary's designee for the state fair hearing.

(d) Any request for a standard or expedited state fair hearing made by telephone or other electronic means and received by the MCE during normal business hours may be accepted as a valid request for a standard or expedited state fair hearing by the MCE if the request and proof of receipt are documented, dated, and reduced to writing by the MCE. The date and time of the telephonic or electronic request for a standard or expedited state fair hearing shall be used to determine the timeliness of the request even if there is a delay by the MCE in reducing the request to writing. Oral, telephonic, or electronic requests for a standard or expedited state fair hearing may not be submitted to the secretary's designee for the state fair hearing.

(e) The MCE shall forward each request for a standard or expedited state fair hearing received by the MCE to the secretary's designee for the state fair hearing within one business day of receipt.

(f) If a written request for a standard or expedited state fair hearing is received by the MCE, the MCE shall date-stamp the request when received as proof of receipt. The timeliness standards specified in subsections (a) and (b) shall apply with the date of receipt by the MCE being used to determine the timeliness of the request.

(g) If the enrollee sends a written request for a standard or expedited state fair hearing directly to the secretary's designee for the state fair hearing, the timeliness standards specified in subsections (a) and (b) shall apply with the date of receipt by the secretary's designee being used to determine the timeliness of the request.

(h) If the request for a standard or expedited state fair hearing is not received within the response periods specified in subsections (a) and (b), the request shall be deemed untimely and shall be dismissed.

(i) The presiding officer shall issue an initial order on a standard or expedited state fair hearing request within the time limits specified in subsections (a) and (b), unless one of the following conditions is met:

(1) The presiding officer cannot reach a decision because the appellant requests a delay or fails to take a required action.

(2) There is an administrative or other emergency beyond the control of the presiding officer or the secretary. The presiding officer shall document the reasons for any delay in the appellant's record.

Kan. Admin. Regs. § 129-8-11

Authorized by and implementing K.S.A. 39-709i, 65-1,254 and 75-7403; adopted by Kansas Register Volume 43, No. 50; effective 12/27/2024.