Kan. Admin. Regs. § 129-9-7

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

Section 129-9-7 - Provider appeal

(a) Any provider may submit a request for an appeal to the MCE if the basis of the request is an action by the MCE as defined in 129-9-1(b)(1)(A) and (b)(1)(B) or a denial of an authorization for a new healthcare service to the enrollee.

(b) Any provider may submit an appeal request or a reconsideration request following receipt of the MCE's notice of action. The provider's right to appeal shall not be dependent upon the completion of the reconsideration process. The MCE may require that the provider submit the appeal in writing. Each written appeal delivered by the postal service or submitted by facsimile to the MCE shall be date-stamped when received by the MCE as proof of receipt. The MCE shall use the date of receipt to determine timeliness of the request.

(c) Each MCE shall provide the opportunity to a provider to submit a request for an appeal following receipt of the MCE's notice of adverse benefit determination or notice of action. For each appeal under this article of the division's regulations to be considered timely pursuant to K.S.A. 39-709h(e)(4) and amendments thereto, the request shall be received by the MCE within 60 days of the date of the notice of adverse benefit determination or 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.

(d) The MCE shall acknowledge, in writing, each appeal received from the provider within 10 days of receipt.

(e) The MCE shall resolve each appeal within 30 days from the date the MCE receives the appeal from the provider and issue a notice of appeal resolution no later than five business days following the date of appeal resolution, pursuant to K.S.A. 39-709h(e)(4) and amendments thereto. The notice of appeal resolution shall meet the requirements specified in 129-9-4.

(f) The provider shall complete the MCE's appeal process before requesting an external independent third-party review pursuant to K.A.R. 129-9-9 or a state fair hearing.

(g) The provider's right to request an appeal shall not be limited or interfered with by the department or the MCE.

(h) The MCE shall cooperate with the state, the state's fiscal agent, or representatives of either to resolve all provider appeals. Cooperation may include providing internal provider appeal information to the state.

Kan. Admin. Regs. § 129-9-7

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.