Kan. Admin. Regs. § 129-9-1 - Applicability; definitions
(a)
Applicability. This article of the division's regulations shall apply to
grievances, reconsiderations, appeals, external independent third-party
reviews, and state fair hearings involving providers of medical care to
enrollees of MCEs and to grievances and state fair hearings involving providers
of medical care to FFS beneficiaries.
(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)
"Action" and "adverse action" mean a decision by the secretary or the MCE to
perform any of the following:
(A) Deny
payment for a requested non-covered service or covered service, in whole or in
part;
(B) determine and recoup an
overpayment of funds made to a provider that was identified through a
post-payment review;
(C) terminate
a KMAP provider's status as a KMAP provider as specified by 129-9-15 . A
decision by the MCE to terminate, suspend, or limit a provider's status as an
MCE network provider shall not be included in this definition; or
(D) deny a provider's KMAP application as
specified by 129-9-15 . A decision by the MCE to deny a provider's application
to be an MCE network provider shall not be included in this
definition.
(2) "Adequate
notice of action" means a written document or remittance advice that is sent by
the MCE to a provider for an action taken, or sent by the secretary to a
provider for an action taken, that meets the requirements specified in 129-9-4
and 129-9-5.
(3) "Adequate notice
of administrative review" means a written document that is sent by the
secretary to a provider that includes the secretary's decision following the
administrative review and that meets the requirements specified in
129-9-5.
(4) "Adequate notice of
appeal resolution" means a written document or remittance advice that is sent
by the MCE to the provider that includes the MCE's resolution of the provider's
appeal request and that meets the requirements specified in 129-9-4.
(5) "Adequate notice of approval" means a
written document or remittance advice that is sent by the MCE to the provider
at the time the MCE approves a service authorization request or payment and
that meets the requirements specified in 129-9-8.
(6) "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 that meets the requirements specified in 129-9-4.
(7) "Adequate notice of reconsideration
resolution" means a written document or remittance advice that is sent by the
MCE to the provider that includes the MCE's resolution of the provider's
reconsideration request and that meets the requirements specified in
129-9-4.
(8) "Administrative
review" means a review by the secretary of evidence submitted by the provider
following notification from the secretary of KMAP's intent to terminate the
provider's participation in KMAP.
(9) "Appeal" means a review by the MCE of an
adverse action or adverse benefit determination. An appeal is not a local
evidentiary hearing, a request for a state fair hearing, or a
grievance.
(10) "Days" means
calendar days, unless otherwise specified.
(11) "External independent third-party
review" means a review by the secretary or secretary's designee of a final
decision of the MCE's internal appeal process involving a denial of an
authorization for a new healthcare service to the enrollee or a claim for
reimbursement to the provider for a healthcare service rendered to the
enrollee.
(12) "Grievance" means
either of the following:
(A) The expression
of dissatisfaction to an MCE by a provider of covered services to an enrollee
about any matter other than an MCE's adverse benefit determination as defined
in 129-8-1 or an MCE's action as defined in this subsection. A provider
submitting a grievance to an MCE shall not have state fair hearing
rights.
(B) The expression of
dissatisfaction to the secretary by a provider of covered services to an FFS
beneficiary about any FFS matter including actions involving payment for FFS
covered services. A provider submitting an FFS grievance shall have state fair
hearing rights if the matter involves an action.
(13) "Grievance and appeal system" means
either of the following:
(A) The grievance,
reconsideration, appeal, and state fair hearing processes that are available to
providers of medical care to enrollees for expressions of dissatisfaction and
for contesting adverse actions regarding payment for covered services rendered
to enrollees, as well as the process to collect and track information;
or
(B) the grievance and state fair
hearing processes that are available to providers of services to FFS
beneficiaries for expressions of dissatisfaction and for contesting adverse
actions regarding payment for covered services rendered to FFS beneficiaries,
as well as the process to collect and track information.
(14) "New healthcare service" means a covered
service that an MCE has not previously authorized or a covered service that an
MCE has previously authorized, for which the authorization period for that
covered service has expired at the time of the request for additional covered
services.
(15) "Non-participating
provider" means a provider without a provider agreement.
(16) "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.
(17) "Participating provider" means a
provider with a provider agreement.
(18) "Provider agreement" means a contract
between a claims reimbursing entity, the secretary or the MCE, and the provider
that specifies the terms and conditions of the provider's participation within
the network of providers created by the reimbursing entity. This term shall
include a contract that is limited by time or instance to specific goods or
services.
(19) "Reconsideration"
means a request by the provider to the MCE to review the MCE's action. A
reconsideration is not an appeal, a request for a state fair hearing, or a
grievance. Submission of a reconsideration request shall be optional and shall
not be required before completion of the required provider appeal
process.
(20) "Reimbursing entity"
means the secretary or the MCE that reviews, determines, and pays claims
submitted by providers.
(21)
"Remittance advice" and "RA" mean a document supplied by the MCE or KMAP that
provides notice and explanation of reasons for payment, adjustment, denial, or
noncovered charge of a medical claim.
(22) "Send" means to deliver by U.S. mail or
in electronic format.
(23) "Timely
notice of action" means an adequate notice of action or remittance advice that
is sent by the MCE or the secretary to the provider within the time frames
specified in 129-9-4 or 129-9-5.
(24) "Timely notice of administrative review"
means an adequate notice of administrative review that is sent by the secretary
to the provider within the time frames specified in 129-9-5.
(25) "Timely notice of appeal resolution"
means an adequate notice of appeal resolution that is sent by the MCE to the
provider within the time frames specified in 129-9-4.
(26) "Timely notice of approval" means an
adequate notice of approval that is sent by the MCE to the provider within the
time frames specified in 129-9-8.
(27) "Timely notice of external review
decision" means an adequate notice of external review decision that is sent by
the MCE to the enrollee and the provider within the time frame specified in
129-9-4.
(28) "Timely notice of
reconsideration resolution" means an adequate notice of reconsideration
resolution or remittance advice that is sent by the MCE to the provider within
the time frame specified in 129-9-4.
Notes
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