Kan. Admin. Regs. § 129-9-5 - Notices to providers rendering services to beneficiaries of the FFS medical assistance program; notices to providers regarding participation in KMAP; applicability
This regulation shall apply to adequate and timely notices of action sent by the secretary to the provider regarding a denial of payment for services rendered to FFS beneficiaries. This regulation shall also apply to adequate and timely notices of action sent by the secretary to the provider regarding termination of the provider's participation in KMAP, denial of a provider's application to KMAP, and to adequate and timely notices of administrative review sent by the secretary to the provider.
(a) An adequate notice of action shall be
sent by the secretary to the provider when the secretary takes an action, as
defined in 129-9-1(b)(1)(A) through (b)(1) (D) . The adequate notice for an
action defined in 129-9-1(b)(1)(A) may take the form of a remittance advice.
Each adequate notice of action shall include the following:
(1) The date of the adequate notice of
action;
(2) the action the
secretary has taken or intends to take;
(3) the date the secretary took the adverse
action or the effective date of the action;
(4) the reasons for the action, including an
explanation of the medical basis for the decision, application of policy, or
accepted standard of medical practice to the beneficiary's medical
circumstances, if the action is based upon a determination that the service is
not medically necessary;
(5) the
statute, regulation, policy, or procedure supporting the action;
(6) for an action defined in
129-9-1(b)(1)(C), an explanation of the provider's right to request an
administrative review before the secretary, the provider's right to present
evidence at the administrative review regarding the proposed termination, and
the procedures by which the provider may submit a request for an administrative
review, including the address and contact information for submission of the
request;
(7) for an action defined
in 129-9-1(b)(1)(C), an explanation of the provider's right to request a state
fair hearing within 30 days of the date of the adequate notice of
administrative review. Three days shall be added to the 30-day response period
if the notice is served by U.S. mail or electronic means;
(8) for an action defined in
129-9-1(b)(1)(C), an explanation of the provider's right to have
self-representation or use legal counsel, a relative, a friend, or a
spokesperson in the administrative review;
(9) an explanation of the provider's right to
request a state fair hearing within 30 days of the date of the adequate notice
of action. Three days shall be added to the 30-day response period if the
notice is served by U.S. mail or electronic means;
(10) the procedures by which the provider may
submit a request for a state fair hearing and the address and contact
information for submission of the request or, for an action based on a change
in law, the circumstances under which a state fair hearing will be
granted;
(11) any change in federal
or state law that requires the action;
(12) an explanation of the provider's right
to have self-representation or use legal counsel, a relative, a friend, or a
spokesperson in the state fair hearing; and
(13) any other information required by Kansas
statute or regulation that involves an adequate notice of action sent by the
secretary.
(b) A timely
notice of action shall be sent by the secretary to the provider no later than
one business day following the date upon which the secretary takes the action
that is the subject of the adequate notice of action. An adequate notice of
action shall be sent by the secretary to the provider as specified in
subsection (a) in accordance with the timeliness standards specified in this
subsection.
(c) An adequate notice
of administrative review shall be sent by the secretary to the provider when
the secretary affirms the decision to terminate a provider's participation in
KMAP. Each adequate notice of administrative review shall include the
following:
(1) The date of the adequate
notice of administrative review;
(2) the action the secretary has taken or
intends to take;
(3) the effective
date of the action;
(4) the reasons
for the action;
(5) the statute,
regulation, policy, or procedure supporting the action;
(6) an explanation of the provider's right to
request a state fair hearing within 30 days of the date of the adequate notice
of administrative review that affirms the decision to terminate the provider's
participation in KMAP. Three days shall be added to the 30-day response period
if the notice is served by U.S. mail or electronic means;
(7) the procedures by which the provider may
submit a request for a state fair hearing and the address and contact
information for submission of the request or, for an action based on a change
in law, the circumstances under which a state fair hearing will be
granted;
(8) any change in federal
or state law that requires the action; and
(9) an explanation of the provider's right to
have self-representation or use legal counsel, a relative, a friend, or a
spokesperson in the state fair hearing.
(d) A timely notice of administrative review
shall be sent by the secretary to the provider no later than one business day
following the date upon which the secretary takes the action that is the
subject of the adequate notice of administrative review. An adequate notice of
administrative review shall be sent by the secretary to the provider as
specified in subsection (c) in accordance with the timeliness standards
specified in this subsection.
(e) A
response by the secretary or department to an inquiry concerning a prior action
shall not be a new action.
Notes
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