Kan. Admin. Regs. § 129-9-15

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

Section 129-9-15 - Provider termination or denial of enrollment

(a) Any provider's participation in KMAP may be terminated by the secretary for one or more of the following reasons:

(1) Voluntary withdrawal of the provider from participation in the program;

(2) non-compliance with applicable state laws, administrative regulations, or program issuances concerning medical providers;

(3) non-compliance with the terms of a provider agreement;

(4) non-compliance with the terms and certification set forth on claims submitted to the secretary for reimbursement;

(5) assignment, granting a power of attorney over, or otherwise transferring right to payment of program claims except as set forth in 42 U.S.C. 1396a (32), as in effect on February 8, 2023, which is hereby adopted by reference;

(6) pattern of submitting inaccurate billings or cost reports;

(7) pattern of submitting billings for services not covered under the program;

(8) pattern of unnecessary utilization;

(9) unethical or unprofessional conduct;

(10) suspension, termination, or expiration of license, registration, or certification in any state;

(11) provision of goods, services, or supplies harmful to individuals or of an inferior quality;

(12) civil or criminal fraud against medicare, the Kansas medicaid or social service programs, or any other state's medicaid or social service programs;

(13) suspension or exclusion by the secretary of health and human services from the title XVIII or title XIX programs;

(14) direct or indirect ownership or controlling interest of five percent or more in a provider institution, organization or agency by a person who has been found guilty of civil or criminal fraud against the medicare program or the Kansas medicaid or social service programs or any other state's medicaid or social service programs;

(15) employment or appointment by a provider of a person in a managerial capacity or as an agent if the person has been found guilty of civil or criminal fraud against the medicare program, or the Kansas medicaid or social service programs, or any other state's medicaid or social service programs;

(16) insolvency;

(17) non-compliance with the requirements of 42 C.F.R. 455.416, as in effect on February 8, 2023, which is hereby adopted by reference; or

(18) discovery of information by the secretary that requires termination pursuant to 42 C.F.R. 455.416.

(b) Prior to the termination of a provider from the program pursuant to subsection (a), an adequate and timely notice of action shall be sent by the secretary to the provider. Each adequate and timely notice of action shall meet the requirements of 129-9-5(a) and (b).

(c) Any provider terminated pursuant to subsection (a) may request an administrative review by the secretary and may request a state fair hearing.

(1) An administrative review shall be scheduled by the secretary not less than five days nor more than 15 days from the date of the adequate notice of action.

(2) All evidence presented, including that of the provider, shall be considered by the secretary in the administrative review. If the decision following the administrative review is to affirm the decision to terminate the provider's participation in KMAP, an adequate and timely notice of administrative review shall be sent by the secretary as specified in 129-9-5(a) and (b).

(d) Termination, unless based upon civil or criminal fraud against the program, suspension or exclusion by the secretary of health and human services, or suspension or exclusion by any other state medicaid agency or medicare, shall remain in effect until the secretary determines that the reason for the termination has been removed and that there is a reasonable assurance that it shall not recur. Terminations based upon civil or criminal fraud shall remain in effect for such time period as deemed appropriate by the secretary. Termination based upon suspension or exclusion by the secretary of health and human services shall remain in effect no less than the time period specified in the notice of suspension issued by the secretary of health and human services. Termination based upon suspension or exclusion by any other state medicaid agency or medicare, shall remain in effect no less than the time period specified by another state medicaid agency or medicare.

(e) A request for reinstatement by a provider terminated from participation in KMAP shall not be considered for a period of 60 days following the effective date of the termination. As a prerequisite for reinstatement in the program, one or more of the following conditions may be imposed by the secretary:

(1) Implementation and documentation of corrective action taken by the provider to comply with program policies and to reasonably ensure that the reason for the termination shall not recur;

(2) probationary period not to exceed one year;

(3) attendance at provider education sessions;

(4) prior authorization of services;

(5) peer supervision; and

(6) other conditions as the specific situation may warrant.

(f) Any provider who is noncompliant with one or more requirements of KMAP participation may be subject to suspension of payment pursuant to 42 C.F.R. 455.23, as in effect on February 8, 2023, which is hereby adopted by reference or other remedies in lieu of termination.

(g) Any provider's application for enrollment in KMAP may be denied by the secretary for one or more of the following reasons:

(1) as required by 42 C.F.R. 455.416;

(2) as required by 42 C.F.R. 455.106, as in effect on February 9, 2023, which is hereby adopted by reference;

(h) Following the denial of a provider's application to KMAP pursuant to subsection (g), an adequate and timely notice of action shall be sent by the secretary to the provider. Each adequate and timely notice of action shall meet the requirements of 129-9-5(a) and (b).

Kan. Admin. Regs. § 129-9-15

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.