Kan. Admin. Regs. § 129-8-8

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

Section 129-8-8 - Notices to enrollees; applicability

This regulation shall apply to adequate and timely notices of approval sent to enrollees by the MCE regarding approval of a covered service authorization request.

(a) Each MCE shall send an adequate notice of approval to the enrollee, the enrollee's authorized representative, and the requesting provider when the MCE fully or partially approves a covered service authorization request submitted by an enrollee or on behalf of an enrollee, when the MCE fully or partially approves a covered service authorization request following an appeal resolution, and when the MCE approves a covered service authorization request following a decision by a presiding officer that reverses the MCE's adverse benefit determination.

(b) Each adequate notice of approval shall include the following:

(1) The date of the adequate notice of approval;

(2) the date the MCE made the approval;

(3) the approval decision the MCE has made, including the dates, types, and amount of service requested; and

(4) the effective date and, if applicable, the end date of the approved covered service authorization request.

(c) The MCE shall send a timely notice of approval to the enrollee, the enrollee's authorized representative, and the requesting provider within the time frames specified in paragraphs (c)(1) through (c)(3). A timely notice of approval shall include the contents of an adequate notice of approval as specified in subsection (b).

(1) The MCE shall send an adequate notice of approval when the MCE approves a covered service authorization request within the following time frames:

(A) For standard authorization decisions, the MCE shall make an authorization decision and send an adequate notice of approval as expeditiously as the enrollee's condition requires and no later than 14 days after the MCE's receipt of the request for service. The MCE may extend the 14-day time period by up to 14 days if the enrollee or the provider requests the extension or the MCE justifies to the secretary, upon the secretary's request, a need for additional information and the reason that the extension is in the enrollee's interest. If the time frame for the decision is extended by up to 14 days, the MCE shall send an adequate notice of approval no later than 28 days after the MCE's receipt of the request for service.

(B) For expedited authorization decisions, if the provider indicates or the MCE determines that following the standard time frame could seriously jeopardize the enrollee's life or health or ability to attain, maintain, or regain maximum function, the MCE shall make an expedited authorization decision and send an adequate notice of approval as expeditiously as the enrollee's health condition requires and no later than 72 hours after the MCE's receipt of the request for service. The MCE may extend the 72-hour time period by up to 14 days if the enrollee or the provider requests the extension or the MCE justifies to the secretary, upon the secretary's request, a need for additional information and how the extension is in the enrollee's interest. If the time frame for the decision is extended by up to 14 days, the MCE shall send an adequate notice of approval no later than 14 days after the date of the extension decision.

(2) The MCE shall send a timely notice of approval when the MCE approves a covered service authorization request following resolution of an enrollee's appeal within the following time frames:

(A) For standard authorization approval decisions made by the MCE following resolution of an appeal, the MCE shall resolve the appeal and send an adequate notice of approval as expeditiously as the enrollee's condition requires and no later than 30 days after the MCE's receipt of the appeal. The MCE may extend the 30-day time period by up to 14 days if the enrollee, or the provider, requests the extension or the MCE justifies to the secretary, upon the secretary's request, a need for additional information and the reason that the extension is in the enrollee's interest. If the resolution time frame is extended by up to 14 days, the MCE shall resolve the appeal and send an adequate notice of approval no later than 14 days after the date of the extension decision.

(B) For expedited authorization approval decisions made by the MCE following resolution of an appeal, if the provider indicates, or the MCE determines, that following the standard time frame for appeal resolution could seriously jeopardize the enrollee's life or health or ability to attain, maintain, or regain maximum function, the MCE shall resolve the appeal and send an adequate notice of approval as expeditiously as the enrollee's health condition requires and no later than 72 hours after the MCE's receipt of the request for appeal. The MCE may extend the 72-hour time period by up to 14 days if the enrollee or the provider requests the extension or the MCE justifies to the secretary, upon the secretary's request, a need for additional information and the reason that the extension is in the enrollee's interest. If the resolution time frame is extended by up to 14 days, the MCE shall resolve the appeal and send an adequate notice of approval no later than 14 days after the date of the extension decision.

(C) If the MCE extends the resolution time frames in paragraph (b)(2)(A) or (b)(2)(B), the MCE shall make reasonable efforts to give the enrollee prompt oral notice of the delay. Within two calendar days, the MCE shall 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. The MCE shall resolve the appeal and send an adequate notice of approval as expeditiously as the enrollee's health condition requires and no later than the date the extension expires.

(3) The MCE shall send a timely notice of approval when a presiding officer reverses an MCE's adverse benefit determination within the time frame specified in this paragraph. For adverse benefit determination decisions reversed by a presiding officer, the MCE shall authorize the disputed services and send an adequate notice of approval as expeditiously as the enrollee's health condition requires and no later than 72 hours after the MCE receives notice of the presiding officer's reversal of the determination. If the department files a petition for review to SAC, the adequate notice of approval shall be delayed until the department receives notice of the SAC decision affirming the presiding officer's reversal of the adverse benefit determination.

Kan. Admin. Regs. § 129-8-8

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.