Kan. Admin. Regs. § 129-9-13

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

Section 129-9-13 - Parties

(a) The parties to each state fair hearing shall be an appellant and a respondent. The case caption in each medical assistance state fair hearing case shall identify the appellant and the respondent as follows:

(1) The named appellant in the case caption shall be a provider, except as specified in subsection (e). Any authorized representative of the provider may request a state fair hearing.

(2) The named respondent in the case caption shall be the department that administers the program or payment for program services involved in the MCE's denial of an authorization for a new healthcare service, the MCE's action, or the secretary's action except as specified in subsection (f).

(A) If the matter involves an MCE's denial of an authorization for a new healthcare service or an MCE's action, the department that administers the program or payment for the program services shall be the real party in interest. The respondent shall be the department and the case caption shall note the MCE beneath the case number. The MCE shall be an interested party in the matter. As an interested party, the MCE, in meeting its contractual responsibilities, shall review the state fair hearing matter to determine whether the following conditions are met:

(i) The MCE appeal process has been completed.

(ii) The matter was filed within the regulatory time frames.

(iii) The matter involves a denial of an authorization for a new healthcare service to the enrollee or a denial of a claim for reimbursement to the provider for an authorization of a new healthcare service rendered to the enrollee.

(B) If the MCE determines that the matter has not met any of the conditions specified in paragraphs (a)(2)(A) (i)-(iii), the MCE, subject to approval by the department, shall submit a request to the presiding officer to dismiss the matter.

(C) If the matter involves an action by the secretary, the department that administers payment for the program services shall be the real party in interest. The respondent shall be the department. The state fair hearing matter shall be reviewed by the secretary or the secretary's designee to determine whether the following conditions are met:

(i) The matter was filed within the regulatory time frames.

(ii) The matter involves an action.

(D) If the secretary determines that the matter has not met either of the conditions specified in paragraphs (a) (2)(C)(i) and (ii), the secretary or the secretary's designee shall submit a request to the presiding officer to dismiss the matter.

(b) The presiding officer conducting the state fair hearing may grant a motion to modify the case caption to clarify the parties.

(c) Any provider may authorize representation by legal counsel, a relative, a friend, or a spokesperson in the state fair hearing if the provider has authorized the representation in writing. This regulation shall not authorize the secretary or the presiding officer to grant exceptions to the Kansas supreme court rules concerning the practice of law in Kansas if the provider is represented by an attorney who is not licensed in Kansas.

(d) The appellant may be a provider in any of the following circumstances:

(1) If the matter involves a denial of an authorization for a new healthcare service made by the MCE against the enrollee, the appellant may be the provider who would have received reimbursement if the MCE had approved the authorization.

(2) If the matter involves an action by an MCE concerning a claim for payment for medical services that have already been provided to the enrollee and the enrollee will not be responsible for the payment of the medical services if the claim is denied by the MCE, the appellant may be the provider.

(3) If the matter involves an adverse benefit determination and an entity other than the provider seeks to be named the appellant, the presiding officer shall determine whether the entity seeking to be named as appellant is the real party in interest instead of the provider.

(e) For each state fair hearing requested by the losing party of the external independent third-party review, the appellant may be the department that administers the program or payment involved in the MCE's denial of an authorization for a new healthcare service or the MCE's action.

(f) For each state fair hearing requested by the losing party of the external independent third-party review, the respondent may be the provider who requested the external independent third-party review.

(g) If a presiding officer allows an entity to intervene in a state fair hearing covered by this article of the division's regulations pursuant to KAPA, the intervening entity shall be identified in the caption of the case as an intervenor.

Kan. Admin. Regs. § 129-9-13

Authorized by and implementing K.S.A. 651,254 and 75-7403; adopted by Kansas Register Volume 43, No. 50; effective 12/27/2024.