Kan. Admin. Regs. § 129-9-13 - Parties
(a) The parties to
each state fair hearing shall be an appellant and a respondent. The case
caption in each medical assistance state fair hearing case shall identify the
appellant and the respondent as follows:
(1)
The named appellant in the case caption shall be a provider, except as
specified in subsection (e). Any authorized representative of the provider may
request a state fair hearing.
(2)
The named respondent in the case caption shall be the department that
administers the program or payment for program services involved in the MCE's
denial of an authorization for a new healthcare service, the MCE's action, or
the secretary's action except as specified in subsection (f).
(A) If the matter involves an MCE's denial of
an authorization for a new healthcare service or an MCE's action, the
department that administers the program or payment for the program services
shall be the real party in interest. The respondent shall be the department and
the case caption shall note the MCE beneath the case number. The MCE shall be
an interested party in the matter. As an interested party, the MCE, in meeting
its contractual responsibilities, shall review the state fair hearing matter to
determine whether the following conditions are met:
(i) The MCE appeal process has been
completed.
(ii) The matter was
filed within the regulatory time frames.
(iii) The matter involves a denial of an
authorization for a new healthcare service to the enrollee or a denial of a
claim for reimbursement to the provider for an authorization of a new
healthcare service rendered to the enrollee.
(B) If the MCE determines that the matter has
not met any of the conditions specified in paragraphs (a)(2)(A) (i)-(iii), the
MCE, subject to approval by the department, shall submit a request to the
presiding officer to dismiss the matter.
(C) If the matter involves an action by the
secretary, the department that administers payment for the program services
shall be the real party in interest. The respondent shall be the department.
The state fair hearing matter shall be reviewed by the secretary or the
secretary's designee to determine whether the following conditions are met:
(i) The matter was filed within the
regulatory time frames.
(ii) The
matter involves an action.
(D) If the secretary determines that the
matter has not met either of the conditions specified in paragraphs (a)
(2)(C)(i) and (ii), the secretary or the secretary's designee shall submit a
request to the presiding officer to dismiss the matter.
(b) The presiding officer
conducting the state fair hearing may grant a motion to modify the case caption
to clarify the parties.
(c) Any
provider may authorize representation by legal counsel, a relative, a friend,
or a spokesperson in the state fair hearing if the provider has authorized the
representation in writing. This regulation shall not authorize the secretary or
the presiding officer to grant exceptions to the Kansas supreme court rules
concerning the practice of law in Kansas if the provider is represented by an
attorney who is not licensed in Kansas.
(d) The appellant may be a provider in any of
the following circumstances:
(1) If the
matter involves a denial of an authorization for a new healthcare service made
by the MCE against the enrollee, the appellant may be the provider who would
have received reimbursement if the MCE had approved the
authorization.
(2) If the matter
involves an action by an MCE concerning a claim for payment for medical
services that have already been provided to the enrollee and the enrollee will
not be responsible for the payment of the medical services if the claim is
denied by the MCE, the appellant may be the provider.
(3) If the matter involves an adverse benefit
determination and an entity other than the provider seeks to be named the
appellant, the presiding officer shall determine whether the entity seeking to
be named as appellant is the real party in interest instead of the
provider.
(e) For each
state fair hearing requested by the losing party of the external independent
third-party review, the appellant may be the department that administers the
program or payment involved in the MCE's denial of an authorization for a new
healthcare service or the MCE's action.
(f) For each state fair hearing requested by
the losing party of the external independent third-party review, the respondent
may be the provider who requested the external independent third-party
review.
(g) If a presiding officer
allows an entity to intervene in a state fair hearing covered by this article
of the division's regulations pursuant to KAPA, the intervening entity shall be
identified in the caption of the case as an intervenor.
Notes
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