Kan. Admin. Regs. § 129-9-4

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

Section 129-9-4 - Notices to providers rendering services to enrollees; applicability

This regulation shall apply to adequate and timely notices of action, adequate and timely notices of reconsideration resolution, adequate and timely notices of appeal resolution, and adequate and timely notices of external review decision issued by the MCE to the provider regarding a denial of payment for services rendered to enrollees. This regulation shall also apply to adequate and timely notices of appeal resolution and adequate and timely notices of external review decision issued by the MCE to the provider and to the affected enrollee regarding a denial of an authorization for a new healthcare service to the enrollee.

(a) The MCE shall send an adequate notice of action to the provider when the MCE takes an action, as defined in 129-9-1(b)(1)(A) and (b)(1)(B) . The adequate notice for an action defined in 129-9-1(b)(1)(A) may take the form of a remittance advice. Each adequate notice of action shall include the following:

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

(2) the action the MCE has taken or intends to take;

(3) the date the MCE made the adverse action;

(4) the reasons for the action, including an explanation of the medical basis for the decision, application of policy, or accepted standard of medical practice to the enrollee's medical circumstances, if the action is based upon a determination that the service is not medically necessary;

(5) the statute, regulation, policy, or procedure supporting the action;

(6) an explanation of the provider's right to request either a reconsideration or an appeal following receipt of the MCE's adequate notice of action;

(7) an explanation of the optional nature of the MCE's reconsideration process and the MCE's requirement for the provider to complete the MCE's appeal process before requesting a state fair hearing;

(8) an explanation of the provider's right to request a reconsideration within 120 days of the date of the adequate notice of action and the provider's right to request an appeal within 60 days of the date of the adequate notice of action. Three days shall be added to the 60-day response period if the notice is served by U.S. mail or electronic means. The adequate notice of action shall include the address and contact information for submission of the reconsideration and submission of the appeal;

(9) an explanation of the provider's right to terminate the reconsideration process and request an appeal with the MCE within 60 days of the date of the adequate notice of action. Three days shall be added to the 60-day response period if the notice is served by U.S. mail or electronic means. The adequate notice of action shall include an explanation that submission of the appeal request is not dependent upon completion of the reconsideration process or receipt of an adequate notice of reconsideration resolution;

(10) an explanation that if the provider chooses to request a reconsideration and wait until receipt of the adequate notice of reconsideration resolution, the provider has the right to request an appeal to the MCE within 60 days of the date of the adequate notice of reconsideration resolution. Three days shall be added to the 60-day response period if the notice is served by U.S. mail or electronic means;

(11) the procedures by which the provider may request a reconsideration or an appeal regarding the MCE's action;

(12) a statement of the provider's right, pursuant to K.S.A. 39-709h(e)(4) and amendments thereto, to request a state fair hearing within 120 days of the date of the adequate notice of appeal resolution. Three days shall be added to the 120-day response period if the notice is served by U.S. mail or electronic means;

(13) the procedures by which the provider may request a state fair hearing and the address and contact information for submission of the request or, for an action based on a change in law, the circumstances under which a state fair hearing will be granted;

(14) any change in federal or state law that requires the action;

(15) a statement of the provider's right to have self-representation or use legal counsel, a relative, a friend, or a spokesperson; and

(16) any other information required by Kansas statute or regulation that involves the MCE's adequate notice of action.

(b) The MCE shall send a timely notice of action to the provider within one business day following the date of action. The MCE shall send an adequate notice of action to the provider as specified in paragraph (a) in accordance with the timeliness standards specified in this subsection.

(c) The MCE shall send an adequate notice of reconsideration resolution to the provider when the MCE reviews a request for reconsideration of an action. Each adequate notice of reconsideration resolution shall include the following:

(1) The date of the adequate notice of reconsideration resolution;

(2) the action that is the subject of the reconsideration;

(3) the results of the resolution process and the date of the reconsideration resolution;

(4) the reasons for the reconsideration resolution, including an explanation of the medical basis for the reconsideration resolution, application of policy, or accepted standard of medical practice to the enrollee's medical circumstances, if the resolution is based upon a determination that the service is not medically necessary;

(5) the statute, regulation, policy, or procedure supporting the reconsideration resolution;

(6) a statement of the provider's right to request an appeal within 60 days of the date of the adequate notice of reconsideration resolution. Three days shall be added to the 60-day response period if the notice is served by U.S. mail or electronic means. The explanation shall include the address and contact information for submission of the request;

(7) the procedures by which a provider may request an appeal following receipt of the MCE's adequate notice of reconsideration resolution;

(8) a statement of the MCE's requirement for the provider to complete the MCE's appeal process before requesting a state fair hearing;

(9) any change in federal or state law that requires the action;

(10) a statement of the provider's right to request a state fair hearing within 120 days of the date of the adequate notice of appeal resolution following completion of the provider appeal process;

(11) the procedures by which the provider may request a state fair hearing and the address and contact information for submission of the request or, for an action based on a change in law, the circumstances under which a state fair hearing will be granted;

(12) an explanation of the provider's right to have self-representation or use legal counsel, a relative, a friend, or a spokesperson; and

(13) any other information required by Kansas statute or regulation that involves the MCE's adequate notice of reconsideration resolution.

(d) The MCE shall send a timely notice of reconsideration resolution to the provider within five business days following the date the MCE resolves the reconsideration. The MCE shall send an adequate notice of reconsideration resolution to the provider as specified in paragraph (c) in accordance with the timeliness standards specified in this subsection.

(e) The MCE shall send an adequate notice of appeal resolution to the provider when the MCE reviews a request for an appeal of an action or an adverse benefit determination. Each adequate notice of appeal resolution shall include the following:

(1) The date of the adequate notice of appeal resolution;

(2) the action or adverse benefit determination that is the subject of the appeal;

(3) the results of the resolution process and the date of the appeal resolution;

(4) the reasons for the appeal resolution, including an explanation of the medical basis for the resolution, application of policy, or accepted standard of medical practice to the enrollee's medical circumstances, if the MCE based its resolution upon a determination that the service is not medically necessary;

(5) the statute, regulation, policy, or procedure supporting the appeal resolution;

(6) a statement that the provider has completed the appeal process with the MCE;

(7) a statement of the provider's right to request an external independent third-party review following receipt of the adequate notice of appeal resolution;

(8) a statement of the procedures by which a provider may request an external independent third-party review with the MCE issuing the decision to be reviewed within 60 days of the date of the adequate notice of appeal resolution. Three days shall be added to the 60-day response period if the notice is served by U.S. mail or electronic means. The explanation shall include the address and contact information for submission of the request;

(9) a statement that if the provider does not request an external independent third-party review, the provider has a right, pursuant to K.S.A. 39-709h(e)(4) and amendments thereto, to request a state fair hearing within 120 days of the date of the adequate notice of appeal resolution. Three days shall be added to the 120-day response period if the notice is served by U.S. mail or electronic means;

(10) the procedures by which the provider may request a state fair hearing and the address and contact information for submission of the request or, for an action based on a change in law, the circumstances under which a state fair hearing will be granted;

(11) a statement of the provider's right to have self-representation or use legal counsel, a relative, a friend, or a spokesperson; and

(12) any other information required by Kansas statute or regulation that involves the MCE's adequate notice of appeal resolution.

(f) The MCE shall send a timely notice of appeal resolution to the provider within five business days following the date the MCE resolves the appeal. The MCE shall send an adequate notice of appeal resolution to the provider as specified in paragraph (e) in accordance with the timeliness standards specified in this subsection.

(g) The MCE shall send an adequate notice of external review decision to the provider following receipt of the external independent third-party reviewer's decision involving a denial of payment and to the provider and the affected enrollee involving a denial of an authorization for a new healthcare service to the enrollee. Each adequate notice of external review decision shall include the following:

(1) The date of receipt of the external review decision;

(2) the date of the adequate notice of the external review decision;

(3) the action or denial of an authorization for a new healthcare service that is the subject of the review;

(4) the results of the review by the external independent third-party reviewer and the date of that decision;

(5) the reasons for the external reviewer's decision, including an explanation of the medical basis for the external review decision, application of policy, or accepted standard of medical practice to the enrollee's medical circumstances, if the external review is based upon a determination by the MCE that the service is not medically necessary;

(6) the statute, regulation, policy, or procedure supporting the external review decision;

(7) a statement of the provider's right to request a state fair hearing within 30 days of the date of the MCE's adequate notice of external review decision. Three days shall be added to the 30-day response period if the notice is served by U.S. mail or electronic means;

(8) the procedures by which the provider may request a state fair hearing and the address and contact information for submission of the request;

(9) a statement of the provider's right to have self-representation or use legal counsel, a relative, a friend, or a spokesperson; and

(10) any other information required by Kansas statute or regulation that involves an MCE's adequate notice of external review decision.

(h) The MCE shall send a timely notice of external review decision to the provider and any affected enrollee within 10 business days following the date the MCE receives the external reviewer's decision. The MCE shall send an adequate notice of external review decision to the provider and any affected enrollee as specified in paragraph (g) in accordance with the timeliness standards specified in this subsection.

(i) A response by the MCE, the secretary, or the department to an inquiry concerning a prior action or denial of an authorization for a new healthcare service shall not be a new action or a new denial of a healthcare service.

Kan. Admin. Regs. § 129-9-4

Authorized by K.S.A. 39-709h(e)(4), 65-1,254 and 75-7403; adopted by Kansas Register Volume 43, No. 50; effective 12/27/2024.