Kan. Admin. Regs. § 129-9-5

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

Section 129-9-5 - Notices to providers rendering services to beneficiaries of the FFS medical assistance program; notices to providers regarding participation in KMAP; applicability

This regulation shall apply to adequate and timely notices of action sent by the secretary to the provider regarding a denial of payment for services rendered to FFS beneficiaries. This regulation shall also apply to adequate and timely notices of action sent by the secretary to the provider regarding termination of the provider's participation in KMAP, denial of a provider's application to KMAP, and to adequate and timely notices of administrative review sent by the secretary to the provider.

(a) An adequate notice of action shall be sent by the secretary to the provider when the secretary takes an action, as defined in 129-9-1(b)(1)(A) through (b)(1) (D) . 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 secretary has taken or intends to take;

(3) the date the secretary took the adverse action or the effective date of the 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 beneficiary'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) for an action defined in 129-9-1(b)(1)(C), an explanation of the provider's right to request an administrative review before the secretary, the provider's right to present evidence at the administrative review regarding the proposed termination, and the procedures by which the provider may submit a request for an administrative review, including the address and contact information for submission of the request;

(7) for an action defined in 129-9-1(b)(1)(C), an explanation of the provider's right to request a state fair hearing within 30 days of the date of the adequate notice of administrative review. Three days shall be added to the 30-day response period if the notice is served by U.S. mail or electronic means;

(8) for an action defined in 129-9-1(b)(1)(C), an explanation of the provider's right to have self-representation or use legal counsel, a relative, a friend, or a spokesperson in the administrative review;

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

(10) the procedures by which the provider may submit a request for 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) any change in federal or state law that requires the action;

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

(13) any other information required by Kansas statute or regulation that involves an adequate notice of action sent by the secretary.

(b) A timely notice of action shall be sent by the secretary to the provider no later than one business day following the date upon which the secretary takes the action that is the subject of the adequate notice of action. An adequate notice of action shall be sent by the secretary to the provider as specified in subsection (a) in accordance with the timeliness standards specified in this subsection.

(c) An adequate notice of administrative review shall be sent by the secretary to the provider when the secretary affirms the decision to terminate a provider's participation in KMAP. Each adequate notice of administrative review shall include the following:

(1) The date of the adequate notice of administrative review;

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

(3) the effective date of the action;

(4) the reasons for the action;

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

(6) an explanation of the provider's right to request a state fair hearing within 30 days of the date of the adequate notice of administrative review that affirms the decision to terminate the provider's participation in KMAP. Three days shall be added to the 30-day response period if the notice is served by U.S. mail or electronic means;

(7) the procedures by which the provider may submit a request for 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;

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

(9) an explanation of the provider's right to have self-representation or use legal counsel, a relative, a friend, or a spokesperson in the state fair hearing.

(d) A timely notice of administrative review shall be sent by the secretary to the provider no later than one business day following the date upon which the secretary takes the action that is the subject of the adequate notice of administrative review. An adequate notice of administrative review shall be sent by the secretary to the provider as specified in subsection (c) in accordance with the timeliness standards specified in this subsection.

(e) A response by the secretary or department to an inquiry concerning a prior action shall not be a new action.

Kan. Admin. Regs. § 129-9-5

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.