205.534 Toll-free telephone line -- Duties relating to adverse determinations -- In-
980 words·~4 min read·
/ky/205-534A research copy — for the controlling text, always check the official state or federal source. Not legal advice.
person meeting -- Reprocessing claims -- Internal appeals -- Timely decisions
on authorization and preauthorization requests -- Monthly reports -- Penalties.
(1)A Medicaid managed care organization shall:
(a)Provide:
1. A toll-free telephone line for providers to contact the insurer for claims
resolution for forty
(40)hours a week during normal business hours in
this state;
2. A toll-free telephone line for providers to submit requests for
authorizations of covered services during normal business hours and
extended hours in this state on Monday and Friday through 6 p.m.,
including federal holidays;
3. With regard to any adverse payment or coverage determination, copies
of all documents, records, and other information relevant to a
determination, including medical necessity criteria and any processes,
strategies, or evidentiary standards relied upon, if requested by the
provider. Documents, records, and other information required to be
provided under this paragraph shall be provided at no cost to the
provider; and
4. For any adverse payment or coverage determination, a written reply in
sufficient detail to inform the provider of all reasons for the
determination. The written reply shall include information about the
provider's right to request and receive at no cost to the provider
documents, records, and other information under subparagraph 3. of this
paragraph;
(b)Afford each participating provider the opportunity for an in-person meeting
with a representative of the managed care organization on:
1. Any clean claim that remains unpaid in violation of KRS 304.17A-700
to 304.17A-730; and
2. Any claim that remains unpaid for forty-five
(45)days or more after the
date the claim is received by the managed care organization and that
individually or in the aggregate exceeds two thousand five hundred
dollars ($2,500);
(c)Reprocess claims that are incorrectly paid or denied in error, in compliance
with KRS 304.17A-708. The reprocessing shall not require a provider to rebill
or resubmit claims to obtain correct payment. No claim shall be denied for
timely filing if the initial claim was timely submitted; and
(d)Establish processes for internal appeals, including provisions for:
1. Allowing a provider to file any grievance or appeal related to the
reduction or denial of the claim within sixty
(60)days of receipt of a
notification from the managed care organization that payment for a
submitted claim has been reduced or denied; and
2. Ensuring the timely consideration and disposition of any grievance or
any appeal within thirty
(30)days from the date the grievance or appeal
is filed with the managed care organization by a provider under this
paragraph.
(a)For the purposes of this subsection:
1. "Timely" means that an authorization or preauthorization request shall
be approved:
a. For an expedited authorization request, within seventy-two
hours after receipt of the request. The timeframe for an expedited
authorization request may be extended by up to fourteen
(14)days
if:
i. The enrollee requests an extension; or
ii. The Medicaid managed care organization justifies to the
department a need for additional information and how the
extension is in the enrollee's interest; and
b. For a standard authorization request, within two
(2)business days.
The timeframe for a standard authorization request may be
extended by up to fourteen
(14)additional days if:
i. The provider or enrollee requests an extension; or
ii. The Medicaid managed care organization justifies to the
department a need for additional information and how the
extension is in the enrollee's interest; and
2. a. "Expedited authorization request" means a request for
authorization or preauthorization where the provider determines
that following the standard a timeframe could seriously jeopardize
an enrollee's life or health, or ability to attain, maintain, or regain
maximum function; and
b. A request for authorization or preauthorization for treatment of an
enrollee with a diagnosis of substance use disorder shall be
considered an expedited authorization request by the provider and
the managed care organization.
(b)A decision by a managed care organization on an authorization or
preauthorization request for physical, behavioral, or other medically necessary
services shall be made in a timely and consistent manner so that Medicaid
members with comparable medical needs receive a comparable, consistent
level, amount, and duration of services as supported by the member's medical
condition, records, and previous affirmative coverage decisions.
(a)Each managed care organization shall report on a monthly basis to the
department:
1. The number and dollar value of claims received that were denied,
suspended, or approved for payment;
2. The number of requests for authorization of services and the number of
such requests that were approved and denied;
3. The number of internal appeals and grievances filed by members and by
providers and the type of service related to the grievance or appeal, the
time of resolution, the number of internal appeals and grievances where
the initial denial was overturned and the type of service and dollar
amount associated with the overturned denials; and
4. Any other information required by the department.
(b)The data required in paragraph
(a)of this subsection shall be separately
reported by provider category, as prescribed by the department, and shall at a
minimum include inpatient acute care hospital services, inpatient psychiatric
hospital services, outpatient hospital services, residential behavioral health
services, and outpatient behavioral health services.
(4)On a monthly basis, the department shall transmit to the Department of Insurance a
report of each corrective action plan, fine, or sanction assessed against a Medicaid
managed care organization for violation of a Medicaid managed care organization's
contract relating to prompt payment of claims. The Department of Insurance shall
then make a determination of whether the contract violation was also a violation of
KRS 304.17A-700 to 304.17A-730.
(5)Any Medicaid managed care organization that fails to comply with KRS 205.522,
205.532 to 205.536, and 304.17A-515 may be subject to fines, penalties, and
sanctions, up to and including termination, as established under its Medicaid
managed care contract with the department.