Kan. Admin. Regs. § 129-9-1

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

Section 129-9-1 - Applicability; definitions

(a) Applicability. This article of the division's regulations shall apply to grievances, reconsiderations, appeals, external independent third-party reviews, and state fair hearings involving providers of medical care to enrollees of MCEs and to grievances and state fair hearings involving providers of medical care to FFS beneficiaries.

(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) "Action" and "adverse action" mean a decision by the secretary or the MCE to perform any of the following:

(A) Deny payment for a requested non-covered service or covered service, in whole or in part;

(B) determine and recoup an overpayment of funds made to a provider that was identified through a post-payment review;

(C) terminate a KMAP provider's status as a KMAP provider as specified by 129-9-15 . A decision by the MCE to terminate, suspend, or limit a provider's status as an MCE network provider shall not be included in this definition; or

(D) deny a provider's KMAP application as specified by 129-9-15 . A decision by the MCE to deny a provider's application to be an MCE network provider shall not be included in this definition.

(2) "Adequate notice of action" means a written document or remittance advice that is sent by the MCE to a provider for an action taken, or sent by the secretary to a provider for an action taken, that meets the requirements specified in 129-9-4 and 129-9-5.

(3) "Adequate notice of administrative review" means a written document that is sent by the secretary to a provider that includes the secretary's decision following the administrative review and that meets the requirements specified in 129-9-5.

(4) "Adequate notice of appeal resolution" means a written document or remittance advice that is sent by the MCE to the provider that includes the MCE's resolution of the provider's appeal request and that meets the requirements specified in 129-9-4.

(5) "Adequate notice of approval" means a written document or remittance advice that is sent by the MCE to the provider at the time the MCE approves a service authorization request or payment and that meets the requirements specified in 129-9-8.

(6) "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 that meets the requirements specified in 129-9-4.

(7) "Adequate notice of reconsideration resolution" means a written document or remittance advice that is sent by the MCE to the provider that includes the MCE's resolution of the provider's reconsideration request and that meets the requirements specified in 129-9-4.

(8) "Administrative review" means a review by the secretary of evidence submitted by the provider following notification from the secretary of KMAP's intent to terminate the provider's participation in KMAP.

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

(10) "Days" means calendar days, unless otherwise specified.

(11) "External independent third-party review" means a review by the secretary or secretary's designee of a final decision of the MCE's internal appeal process involving a denial of an authorization for a new healthcare service to the enrollee or a claim for reimbursement to the provider for a healthcare service rendered to the enrollee.

(12) "Grievance" means either of the following:

(A) The expression of dissatisfaction to an MCE by a provider of covered services to an enrollee about any matter other than an MCE's adverse benefit determination as defined in 129-8-1 or an MCE's action as defined in this subsection. A provider submitting a grievance to an MCE shall not have state fair hearing rights.

(B) The expression of dissatisfaction to the secretary by a provider of covered services to an FFS beneficiary about any FFS matter including actions involving payment for FFS covered services. A provider submitting an FFS grievance shall have state fair hearing rights if the matter involves an action.

(13) "Grievance and appeal system" means either of the following:

(A) The grievance, reconsideration, appeal, and state fair hearing processes that are available to providers of medical care to enrollees for expressions of dissatisfaction and for contesting adverse actions regarding payment for covered services rendered to enrollees, as well as the process to collect and track information; or

(B) the grievance and state fair hearing processes that are available to providers of services to FFS beneficiaries for expressions of dissatisfaction and for contesting adverse actions regarding payment for covered services rendered to FFS beneficiaries, as well as the process to collect and track information.

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

(15) "Non-participating provider" means a provider without a provider agreement.

(16) "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.

(17) "Participating provider" means a provider with a provider agreement.

(18) "Provider agreement" means a contract between a claims reimbursing entity, the secretary or the MCE, and the provider that specifies the terms and conditions of the provider's participation within the network of providers created by the reimbursing entity. This term shall include a contract that is limited by time or instance to specific goods or services.

(19) "Reconsideration" means a request by the provider to the MCE to review the MCE's action. A reconsideration is not an appeal, a request for a state fair hearing, or a grievance. Submission of a reconsideration request shall be optional and shall not be required before completion of the required provider appeal process.

(20) "Reimbursing entity" means the secretary or the MCE that reviews, determines, and pays claims submitted by providers.

(21) "Remittance advice" and "RA" mean a document supplied by the MCE or KMAP that provides notice and explanation of reasons for payment, adjustment, denial, or noncovered charge of a medical claim.

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

(23) "Timely notice of action" means an adequate notice of action or remittance advice that is sent by the MCE or the secretary to the provider within the time frames specified in 129-9-4 or 129-9-5.

(24) "Timely notice of administrative review" means an adequate notice of administrative review that is sent by the secretary to the provider within the time frames specified in 129-9-5.

(25) "Timely notice of appeal resolution" means an adequate notice of appeal resolution that is sent by the MCE to the provider within the time frames specified in 129-9-4.

(26) "Timely notice of approval" means an adequate notice of approval that is sent by the MCE to the provider within the time frames specified in 129-9-8.

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

(28) "Timely notice of reconsideration resolution" means an adequate notice of reconsideration resolution or remittance advice that is sent by the MCE to the provider within the time frame specified in 129-9-4.

Kan. Admin. Regs. § 129-9-1

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.