Kan. Admin. Regs. § 129-9-7 - Provider appeal
(a) Any
provider may submit a request for an appeal to the MCE if the basis of the
request is an action by the MCE as defined in 129-9-1(b)(1)(A) and (b)(1)(B) or
a denial of an authorization for a new healthcare service to the
enrollee.
(b) Any provider may
submit an appeal request or a reconsideration request following receipt of the
MCE's notice of action. The provider's right to appeal shall not be dependent
upon the completion of the reconsideration process. The MCE may require that
the provider submit the appeal in writing. Each written appeal delivered by the
postal service or submitted by facsimile to the MCE shall be date-stamped when
received by the MCE as proof of receipt. The MCE shall use the date of receipt
to determine timeliness of the request.
(c) Each MCE shall provide the opportunity to
a provider to submit a request for an appeal following receipt of the MCE's
notice of adverse benefit determination or notice of action. For each appeal
under this article of the division's regulations to be considered timely
pursuant to
K.S.A.
39-709h(e)(4) and amendments
thereto, the request shall be received by the MCE within 60 days of the date of
the notice of adverse benefit determination or notice of action. Three days
shall be added to the 60-day response period if the notice is served by U.S.
mail or electronic means.
(d) The
MCE shall acknowledge, in writing, each appeal received from the provider
within 10 days of receipt.
(e) The
MCE shall resolve each appeal within 30 days from the date the MCE receives the
appeal from the provider and issue a notice of appeal resolution no later than
five business days following the date of appeal resolution, pursuant to
K.S.A.
39-709h(e)(4) and amendments
thereto. The notice of appeal resolution shall meet the requirements specified
in 129-9-4.
(f) The provider shall
complete the MCE's appeal process before requesting an external independent
third-party review pursuant to
K.A.R.
129-9-9 or a state fair hearing.
(g) The provider's right to request an appeal
shall not be limited or interfered with by the department or the MCE.
(h) The MCE shall cooperate with the state,
the state's fiscal agent, or representatives of either to resolve all provider
appeals. Cooperation may include providing internal provider appeal information
to the state.
Notes
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