Kan. Admin. Regs. § 129-8-7

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

Section 129-8-7 - Enrollee appeal

(a) Any enrollee may submit a request for an appeal to the MCE if the basis of the request is an adverse benefit determination.

(b) Any enrollee may submit an oral or written appeal to the MCE. Any enrollee may request an appeal in person, by telephone, by U.S. mail, or by facsimile. Each written appeal delivered by the postal service or submitted by facsimile to the MCE shall be date-stamped when received by the MCE as proof of receipt. The MCE shall use the date of receipt to determine timeliness of the request.

(c) Following receipt of an oral appeal, the MCE shall attempt to obtain the appeal in writing. The MCE shall not require a written form from the enrollee for an oral appeal and shall process and resolve the oral appeal in accordance with subsections (d) through (g).

(d) Each MCE shall provide the enrollee with the opportunity to submit a request for an appeal following receipt of the MCE's notice of adverse benefit determination. For each appeal under this article of the division's regulations to be considered timely, the request shall be received by the MCE within 60 days from the date of the notice of adverse benefit determination. Three days shall be added to the 60-day response period if the notice is served by U.S. mail or electronic means.

(e) The MCE shall acknowledge, in writing, each appeal received from the enrollee within five days of receipt.

(f) The MCE shall resolve each appeal and send a notice of appeal resolution within 30 days from the date the MCE receives the appeal from the enrollee, unless the appeal requires expedited resolution. The notice of appeal resolution shall meet the requirements specified in 129-8-4 .

(1) The MCE may extend this 30-day resolution time period up to 14 days if the enrollee requests the extension or the MCE shows, to the satisfaction of the secretary, upon the secretary's request, that there is need for additional information and how the delay is in the enrollee's interest.

(2) If the MCE extends the time frame not at the request of the enrollee, the MCE shall perform the following:

(A) Make reasonable efforts to give the enrollee prompt oral notice of the delay;

(B) within two days, give the enrollee written notice of the reason for the decision to extend the time frame and inform the enrollee of the right to file a grievance if the enrollee disagrees with that decision; and

(C) resolve the appeal as expeditiously as the enrollee's health condition requires and no later than the date the extension expires.

(g) Each MCE shall provide the enrollee with the opportunity to submit a request for an expedited appeal if the enrollee indicates that there is a risk to the enrollee's life, physical or mental health, or ability to attain, maintain, or regain maximum function. Each MCE shall establish and maintain an expedited review process for appeals if the MCE determines that taking the time for a standard resolution could seriously jeopardize the enrollee's life, physical or mental health, or ability to attain, maintain, or regain maximum function.

(1) The MCE shall resolve expedited appeals and issue a notice of appeal resolution within 72 hours from the time the MCE received the earliest request for an expedited appeal from the enrollee. The notice of appeal resolution shall meet the requirements specified in 129-8-4.

(2) The MCE may extend the 72-hour resolution time period up to 14 days if the enrollee requests the extension or the MCE shows to the satisfaction of the secretary, upon the secretary's request, that there is need for additional information and how the delay is in the enrollee's interest.

(3) If the MCE extends the time frame not at the request of the enrollee, the MCE shall complete the following:

(A) Make reasonable efforts to give the enrollee prompt oral notice of the delay;

(B) within two calendar days, give the enrollee written notice of the reason for the decision to extend the time frame and inform the enrollee of the right to file a grievance if the individual disagrees with that decision; and

(C) resolve the appeal as expeditiously as the enrollee's health condition requires and no later than the date the extension expires.

(h) The enrollee shall complete the MCE's appeal process before requesting a state fair hearing.

(i) If the MCE fails to adhere to the resolution and notification requirements in this regulation or in 1298-3, the enrollee shall be deemed to have exhausted the MCE's appeal process. The enrollee may initiate a state fair hearing.

(j) The enrollee's right to request an appeal shall not be limited or interfered with by the department or the MCE.

(k) The MCE shall consider the enrollee or an estate representative of a deceased enrollee as a party to the appeal. The enrollee may seek a state fair hearing if the enrollee is not satisfied with the MCE decision in response to an appeal.

(l) If the MCE reverses a decision to deny, limit, or delay covered services that were not furnished while the appeal was pending, the MCE shall authorize or provide the disputed covered services promptly and as expeditiously as the enrollee's health condition requires but no later than 72 hours from the date the MCE reverses its decision.

(m) If the MCE reverses a decision to deny authorization of covered services and the enrollee received the disputed covered services while the appeal was pending, the MCE shall pay for those covered services.

(n) The MCE shall ensure that punitive action is not taken against any provider who requests an appeal on the enrollee's behalf or supports the enrollee's appeal request.

(o) The MCE shall cooperate with the secretary, the secretary's fiscal agent, or representatives of either to resolve all enrollee appeals. Cooperation may include providing internal enrollee appeal information to the state.

Kan. Admin. Regs. § 129-8-7

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.