Kan. Admin. Regs. § 129-8-10 - When a state fair hearing is required
(a) Any enrollee may submit a request for a
standard state fair hearing if the enrollee identifies an adverse benefit
determination by the MCE or an action by the secretary to deny the enrollee's
request to disenroll from the enrollee's current MCE, as the basis for the
request. Any enrollee may submit a request for a state fair hearing following
receipt of the MCE's notice of external review decision if the enrollee
identifies the MCE's denial of an authorization for a new healthcare service
that was the subject of the external review as the basis for the
request.
(b) If the basis for the
state fair hearing request is an adverse benefit determination by the MCE, the
enrollee shall complete the appeal process with the MCE before requesting a
standard state fair hearing. The enrollee shall meet the requirements stated in
a state plan, an amendment to a state plan, a waiver, or a CMS-approved
contract between the secretary and the MCE before the enrollee may request a
state fair hearing. Failure to meet any contractual preconditions shall be
grounds for dismissing the request for a state fair hearing. The enrollee shall
submit the request for a state fair hearing in accordance with the timeliness
requirements in 129-8-11(a)(1).
(c)
Any enrollee may submit a request for an expedited state fair hearing if the
enrollee has completed the appeal process with the MCE, an adverse benefit
determination by an MCE is identified as the basis for the request, and the MCE
determines that the expedited state fair hearing request meets one of the
following conditions:
(1) The enrollee met
the criteria for expedited appeal resolution, but the appeal was not resolved
within the time frame for expedited resolution.
(2) The appeal was resolved within the time
frame for expedited resolution, but the MCE reached a decision wholly or
partially adverse to the enrollee.
(d) The enrollee's request for an expedited
state fair hearing, when combined with the secretary's approval, shall
constitute a mutual waiver of procedural time requirements otherwise required
by law that would defeat the purpose for the expedited state fair hearing. The
enrollee shall submit the request for an expedited state fair hearing in
accordance with the timeliness requirements in 129-8-11(b).
(e) If the basis for the state fair hearing
request is a denial of an authorization for a new healthcare service by the MCE
and the denial has been reviewed by the external independent third-party
reviewer, the enrollee shall first meet any requirements stated in a state
plan, an amendment to a state plan, a waiver, or a CMS-approved contract
between the secretary and the MCE before the enrollee may seek a state fair
hearing. Failure to meet any contractual preconditions shall be grounds for
dismissing the request for a state fair hearing. The enrollee shall submit the
request for a state fair hearing in accordance with the timeliness requirements
in 129-8-11(a)(2).
(f) If the
request for a state fair hearing concerns a matter that the MCE, by the terms
of the managed care contract, does not handle or make decisions upon, the MCE
shall forward the request to the secretary for routing to the appropriate
entity for processing the request for a state fair hearing.
(g) If the basis for the state fair hearing
request is a denial of the enrollee's disenrollment request by the secretary,
the enrollee shall not be required to complete the appeal process with the MCE
before requesting a standard state fair hearing. The enrollee shall submit the
request for a state fair hearing in accordance with the timeliness requirements
in 129-8-11(a)(3).
(h) The granting
of a state fair hearing shall not be required of the secretary if the sole
issue is a federal or state law requiring an automatic change adversely
affecting some or all enrollees.
(i) Each request for a state fair hearing
received by the secretary or the MCE shall be forwarded to the secretary's
designee for the state fair hearing within one business day by the secretary or
the MCE. Each oral request for a state fair hearing shall be reduced to writing
by the secretary or the MCE before the request is forwarded.
(j) The enrollee's right to request a state
fair hearing shall not be limited or interfered with by the secretary or the
MCE.
Notes
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