Kan. Admin. Regs. § 129-8-17 - Department's summary

(a) Within 30 days of the date of the acknowledgement and order issued by the presiding officer in response to a request for state fair hearing, the appellant and the presiding officer shall be furnished by the department with a summary providing the following information and exhibits:

(1) The appellant's name and address;

(2) a summary statement concerning why the appellant is filing a request for a state fair hearing;

(3) a brief and relevant chronological summary of the events that occurred in relationship to the appellant's request for a state fair hearing;

(4) a statement of the basis of the adverse benefit determination;

(5) a citation to and copy of the applicable policies or member handbook excerpts relied upon for the adverse benefit determination. The applicable medical necessity criteria or guidelines used in making medical necessity decisions shall be included;

(6) a citation to or copy of the applicable Kansas and federal statutes and regulations relied upon for the adverse benefit determination;

(7) a citation to or copy of the applicable state plan or waiver documents relied upon for the adverse benefit determination;

(8) a copy of the notice that notified the appellant of the decision in question and any subsequent notices;

(9) a copy of any applicable correspondence;

(10) the name and title of each person who will testify or represent the department at the state fair hearing; and

(11) for state fair hearings involving a decision by the external independent third-party reviewer, copies of the notice of provider appeal resolution, all of the provider appeal documentation submitted to and reviewed by the external reviewer, the MCE's acknowledgement of receipt of the request for external review, the external reviewer's decision letter, and the MCE's notice of external reviewer's decision.

(b) Upon written request by the department, the presiding officer assigned to the state fair hearing may grant additional time for the completion of the summary. The presiding officer shall file notification of the approval or denial of the extension request. If approved, the notification shall include the revised due date for the department's summary.

(c) If the responsibility for the preparation of the department's summary has been given to the secretary's designee, the secretary's designee shall meet the requirements of this regulation and any additional directives by the department.

(d) If a member or a provider submits a state fair hearing request regarding an MCE's decision that is subsequently reviewed by the external independent third-party reviewer and a department summary has been submitted to the presiding officer for one or both state fair hearing requests, the department or the department's designee shall not be required to submit a second department summary if a member or a provider submits a state fair hearing request regarding the same MCE decision following the decision by the external independent third-party reviewer. An addendum to the department summary may be submitted in lieu of an additional department summary.

(e) If the state fair hearing request involves a decision by the external independent third-party reviewer and the department is the appellant, the department or the department's designee shall furnish to the respondent and the presiding officer a summary providing the information and exhibits specified in subsection (a). The exhibits shall include all documents reviewed and relied upon by the external independent third-party reviewer for its decision.

(f) The department's summary shall be submitted to the presiding officer and the appellant within 30 days as specified in subsection (a) or by the date approved by the presiding officer as specified in subsection (b) unless there is an administrative or other emergency beyond the control of the presiding officer or the department. The due date for the department's summary may be modified by the presiding officer before or after the administrative or other emergency.

Notes

Kan. Admin. Regs. § 129-8-17

Authorized by and implementing K.S.A. 65-1,254 and 75-7403; effective, T-129-1-6-23, Jan. 6, 2023; adopted by Kansas Register Volume 43, No. 50; effective 12/27/2024.