Kan. Admin. Regs. § 129-9-8

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

Section 129-9-8 - Notices to providers rendering covered services to enrollees and FFS beneficiaries; applicability

This regulation shall apply to adequate and timely notices of approval sent to providers by the MCE or the secretary regarding approval of payment, approval of an enrollee covered service authorization request, or approval of an FFS covered service authorization request.

(a) Each MCE shall send an adequate notice of approval to the provider when the MCE fully or partially approves payment to the provider following a claim submission for covered services rendered to an MCE enrollee, when the MCE fully or partially approves a covered service authorization request submitted by a provider on behalf of an enrollee, when the MCE fully or partially approves payment following a reconsideration resolution, when the MCE fully or partially approves payment or a covered service authorization request following an appeal resolution, and when the MCE approves payment or a covered service authorization request following a decision by a presiding officer that reverses the MCE's action or adverse benefit determination. The adequate notice of approval involving payment may take the form of a remittance advice.

(b) An adequate notice of approval shall be sent when the secretary fully or partially approves payment to the provider following a claim submission for covered services rendered to an FFS beneficiary, when the secretary fully or partially approves a covered service authorization request submitted by a provider on behalf of an FFS beneficiary, and when the secretary approves payment or an FFS covered service authorization request following a decision by a presiding officer that reverses the secretary's action. The adequate notice of approval involving payment may take the form of a remittance advice.

(c) Each adequate notice of approval shall include the following:

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

(2) the date the MCE made the approval;

(3) the approval decision the MCE has made, including the dates and type of service requested, if the approval is for payment, and the dates, types, and amount of service requested if the approval is for a covered service authorization request; and

(4) the effective date and, if applicable, the end date of the approved covered service authorization request.

(d) The MCE shall send a timely notice of approval to the provider within the time frames specified in paragraphs (d)(1) through (d)(5). A timely notice of approval shall include the contents of an adequate notice of approval as specified in subsection (c).

(1) For approval of full or partial payment for enrollee covered services following a claim submission, the MCE shall send an adequate notice of approval to the provider within one business day of the approval decision.

(2) For approval of a standard or expedited covered service authorization request submitted by a provider on behalf of an enrollee, the MCE shall send an adequate notice of approval to the requesting provider within the time frames specified in 129-8-8(c)(1).

(3) For approval of full or partial payment following an MCE's reconsideration resolution, the MCE shall send an adequate notice of approval to the provider within five business days of the approval decision.

(4) For approval of full or partial payment following an MCE's appeal resolution, the MCE shall send an adequate notice of approval to the provider within five business days of the approval decision.

(5) For approval of full or partial payment or approval of a covered service authorization request following a presiding officer's reversal of an MCE's action or adverse benefit determination, the MCE shall send an adequate notice of approval within the following time frames:

(A) For adverse payment decisions reversed by a presiding officer, the MCE shall authorize payment and send an adequate notice of approval within five business days of the date the MCE receives notice of the presiding officer's reversal of the MCE's action. If the department files a petition for review to SAC, the adequate notice of approval shall be delayed until the department receives notice of the SAC decision affirming the presiding officer's reversal of the action. The MCE shall send an adequate notice of approval within five business days of the date the MCE receives notice of the SAC decision.

(B) For adverse benefit determination decisions reversed by a presiding officer, the MCE shall authorize the disputed services and send an adequate notice of approval as expeditiously as the enrollee's health condition requires and no later than 72 hours after the MCE receives notice of the presiding officer's reversal of the MCE's determination. If the department files a petition for review to SAC, the adequate notice of approval shall be delayed until the department receives notice of the SAC decision affirming the presiding officer's reversal of the adverse benefit determination. The MCE shall send an adequate notice of approval no later than 72 hours after the date the MCE receives notice of the SAC decision.

(e) A timely notice of approval shall be sent by the secretary or the secretary's designee to the provider within the time frames specified in paragraphs (e)(1) through (e) (4). A timely notice of approval shall include the contents of an adequate notice of approval as specified in subsection (c).

(1) For approval of full or partial payment for FFS covered services following a claim submission, an adequate notice of approval shall be sent by the secretary to the provider within seven business days of the approval decision.

(2) For adverse payment decisions reversed by a presiding officer, payment for FFS covered services shall be authorized by the secretary and an adequate notice of approval shall be sent by the secretary within seven business days of the date the secretary receives notice of the presiding officer's reversal of the secretary's action. If a petition for review to SAC is filed by the secretary, the adequate notice of approval shall be delayed until notice of the SAC decision affirming the presiding officer's reversal of the secretary's action is received by the secretary. An adequate notice of approval shall be sent by the secretary to the provider no later than seven business days following the date upon which the secretary receives notice of the SAC decision.

(3) For approval of an FFS covered service authorization request submitted by a provider on behalf of an FFS beneficiary, an adequate notice of approval shall be sent by the secretary to the requesting provider within three business days of the approval decision.

(4) For adverse FFS covered service authorization decisions reversed by a presiding officer, the disputed services shall be authorized by the secretary and an adequate notice of approval shall be sent by the secretary within three business days after the date the secretary receives notice of the presiding officer's reversal of the secretary's action. If a petition for review to SAC is filed by the secretary, the adequate notice of approval shall be delayed until notice of the SAC decision affirming the presiding officer's reversal of the secretary's action is received by the secretary.

Kan. Admin. Regs. § 129-9-8

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.