Kan. Admin. Regs. § 129-8-21

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

Section 129-8-21 - Presiding officer; decisions

(a) The presiding officer shall conduct a state fair hearing requested by an appellant concerning an adverse benefit determination as defined in 129-8-1, a denial by the secretary of the enrollee's request to disenroll from the enrollee's MCE, or a decision by the external independent third-party reviewer.

(b) The presiding officer assigned to administer the state fair hearing shall weigh the evidence and determine the facts and conclusions of law pertinent to the state fair hearing.

(c) The presiding officer shall determine the facts and conclusions of law based on supporting and detracting testimony, documents, statutes, regulations, the state plan and its amendments, and policies allowed into the record of the state fair hearing by the presiding officer.

(d) The presiding officer shall control the state fair hearing. Unless preempted by federal or state law, the presiding officer conducting a state fair hearing under this article of the division's regulations shall use KAPA and may use Kansas civil procedure in the state fair hearing as needed.

(e) The presiding officer shall determine the basis for the state fair hearing.

(f) If the presiding officer determines the state fair hearing in favor of the appellant, the remedy ordered by the presiding officer shall be limited to orders that are within the lawful authority of the secretary to execute.

(g) For state fair hearings that do not involve a decision by the external independent third-party review, the presiding officer shall determine whether the adverse benefit determination made by the respondent is due to a correct interpretation of the applicable statute, regulation, or policy. If the presiding officer determines the state fair hearing in favor of the respondent, the presiding officer shall affirm the adverse benefit determination of the respondent. If the presiding officer determines the state fair hearing in favor of the appellant, the remedy ordered by the presiding officer shall be limited to orders that are within the lawful authority of the secretary to execute.

(h) For state fair hearings that involve a decision by the external independent third-party review, the presiding officer shall determine whether the decision made by the external independent third-party reviewer is due to a correct interpretation of the applicable statute, regulation, or policy.

(1) If the presiding officer determines the state fair hearing in favor of the respondent and the respondent is a department, the remedy ordered by the presiding officer shall be limited to orders that affirm the department's action reviewed by the external independent third-party reviewer. If the presiding officer determines the state fair hearing in favor of the appellant and the appellant is the enrollee, the remedy ordered by the presiding officer shall be limited to orders that reverse the department's action or denial of an authorization for a new healthcare service reviewed by the external independent third-party reviewer. The presiding officer shall issue orders that are within the lawful authority of the secretary to execute.

(2) If the presiding officer determines the state fair hearing in favor of the respondent and the respondent is the enrollee, the remedy ordered by the presiding officer shall be limited to orders that reverse the department's action or denial of an authorization for a new healthcare service reviewed by the external independent third-party reviewer. If the presiding officer determines the state fair hearing in favor of the appellant and the appellant is a department, the remedy ordered by the presiding officer shall be limited to orders that affirm the department's action or denial of an authorization for a new healthcare service reviewed by the external independent third-party reviewer. The presiding officer shall issue orders that are within the lawful authority of the secretary to execute.

(i) If the presiding officer determines that the adverse benefit determination challenged by the appellant required sequential decisions by the same department, or by two or more departments, before a decision could be correctly determined and that the sequential process had not been completed, the presiding officer may remand the matter to the department that last took action in the matter. The presiding officer may direct the departments to complete the sequential process, including forwarding the matter to the next department in sequence, as the remedy. The presiding officer may determine whether to keep the current state fair hearing case open pending the completion of the process or to dismiss the case.

Kan. Admin. Regs. § 129-8-21

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