Kan. Admin. Regs. § 129-8-1 - Applicability; definitions
(a)
Applicability. This article of the division's regulations shall apply to
grievances, appeals, and state fair hearings involving medical assistance
enrollees who are receiving covered services from a managed care entity with a
CMS approved contract with the secretary.
(b) Definitions. For purposes of this article
of the division's regulations, each of the following terms shall have the
meaning specified in this regulation:
(1)
"Adequate notice of adverse benefit determination" means a written document
that is sent by the MCE to the enrollee or requesting provider at the time the
MCE makes an adverse benefit determination and that meets the requirements
specified in 129-8-4.
(2) "Adequate
notice of appeal resolution" means a written document that is sent by the MCE
to the enrollee and requesting provider that includes the MCE's resolution of
the enrollee's appeal request and that meets the requirements specified in
129-8-4.
(3) "Adequate notice of
approval" means a written document that is sent by the MCE to the enrollee and
the requesting provider at the time the MCE approves a covered service
authorization request and that meets the requirements specified in
129-8-8.
(4) "Adequate notice of
external review decision" means a written document that is sent by the MCE to
the enrollee and the provider that includes the external independent
third-party reviewer's decision and meets the requirements specified in
129-9-4.
(5) "Adverse benefit
determination" means a decision by the MCE for any of the following:
(A) The denial or limited authorization of a
requested non-covered service or covered service, including determinations
based on the type or level of service, requirements for medical necessity,
appropriateness, setting, or effectiveness of a covered service;
(B) the reduction, suspension, or termination
of a previously authorized covered service;
(C) the failure to provide covered services
in a timely manner, as defined by the secretary;
(D) the failure of the MCE to act within
required time frames, which constitutes a denial and an adverse benefit
determination and are the following:
(i) The
failure to resolve a grievance and send notice within the time frames specified
in 129-8-3 ;
(ii) the failure of
the MCE to resolve an appeal and send notice within the time frames specified
in 129-8-7 ; and
(iii) the failure
of the MCE to reach service authorization decisions within the time frames
specified in 129-8-4 ;
(E) the denial of the enrollee's request to
dispute a financial liability, including cost sharing, copayments, premiums,
deductibles, coinsurance, and other enrollee financial liabilities;
and
(F) the placement of the
enrollee into administrative lock-in due to the enrollee's persistent
noncompliance with the requirements of care and treatment, abusive or
threatening conduct by the enrollee, fraud or waste by the enrollee, or overuse
of covered services, including LTSS, at a frequency or amount that is not
medically necessary.
(6)
"Appeal" means a review by the MCE of an adverse benefit determination. An
appeal is not a local evidentiary hearing, a request to the presiding officer
for a state fair hearing, or a grievance.
(7) "Days" means calendar days unless
otherwise specified.
(8)
"Grievance" means the expression of dissatisfaction to an MCE by the enrollee
about any matter other than an adverse benefit determination. This term may
include dissatisfaction with the quality of care or services provided, aspects
of interpersonal relationships including rudeness of the provider or employee,
and failure to respect the enrollee's rights regardless of whether the enrollee
requests remedial action. This term shall include the enrollee's right to
dispute an extension of time proposed by the MCE to make an authorization
decision or resolve an appeal or grievance. An enrollee submitting a grievance
shall not have state fair hearing rights.
(9) "Grievance and appeal system" means the
grievance, appeal, and state fair hearing processes that are available to
enrollees for expressions of dissatisfaction and for contesting adverse benefit
determinations regarding covered services and non-covered services, as well as
the process by which information is collected and tracked.
(10) "Lock-in" means the MCE's restriction of
the enrollee's access to medical services because of the enrollee's abuse of
medical services. Lock-in is accomplished through limitation of the use of the
MCE's medical identification card to designated medical providers.
(11) "New healthcare service" means a covered
service that an MCE has not previously authorized or a covered service that an
MCE has previously authorized, but the authorization period for that covered
service has expired at the time of the request for additional covered
services.
(12) "PCCM" means a
primary care case manager, including a physician, a physicians' group practice,
or an entity that uses physicians, who provides primary care to the enrollee
under a contract with the Kansas medical assistance program.
(13) "Send" means to deliver by U.S. mail or
in electronic format.
(14) "Timely
notice of adverse benefit determination" means an adequate notice of adverse
benefit determination sent by the MCE to the enrollee within the time frames
specified in 129-8-4.
(15) "Timely
notice of appeal resolution" means an adequate notice of appeal resolution that
is sent by the MCE to the enrollee within the time frames specified in
129-8-7.
(16) "Timely notice of
approval" means an adequate notice of approval that is sent by the MCE to the
enrollee within the time frames specified in 129-8-8.
(17) "Timely notice of external review
decision" means an adequate notice of external review decision that is sent by
the MCE to the enrollee and requesting provider within the time frame specified
in 129-9-4.
Notes
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