205.646 External independent third-party review of Medicaid managed care
616 words·~3 min read·
/ky/205-646A research copy — for the controlling text, always check the official state or federal source. Not legal advice.
organization's final decision denying a health care service or a claim for
reimbursement -- Submission of multiple claims in a single review -- Appeal --
Administrative regulations -- Applicability of statute.
(1)As used in this section:
(a)"Administrative appeals hearing" means a formal adjudicatory proceeding
conducted by the Office of Administrative Hearings within the Department of
Law in accordance with KRS Chapter 13B;
(b)"Department" means the Department for Medicaid Services;
(c)"External independent third-party review" means a review performed by an
independent third party outside of the Medicaid managed care organization's
internal appeal process pursuant to administrative regulations promulgated by
the department;
(d)"Medicaid managed care organization" means an entity for which the
Department for Medicaid Services has contracted to serve as a managed care
organization as defined in 42 C.F.R. sec. 438.2; and
(e)"Provider" means any person or entity licensed in Kentucky as defined in
KRS 304.17A-700(9) that provides covered services to enrollees.
(2)Notwithstanding any law to the contrary, a provider who has exhausted the written
internal appeals process of a Medicaid managed care organization shall be entitled
to an external independent third-party review of the Medicaid managed care
organization's final decision that denies, in whole or in part, a health care service to
an enrollee or a claim for reimbursement to a provider for a health care service
rendered by the provider to an enrollee of the Medicaid managed care organization.
A provider may submit multiple claims to be appealed in a single external
independent third-party review if the provider alleges that a Medicaid managed care
organization has implemented a policy or practice that results in the denial, in
whole or in part, of those claims.
(3)A Medicaid managed care organization's letter to a provider reflecting the final
decision of the provider's internal appeal shall include:
(a)A statement that the provider's internal appeal rights within the Medicaid
managed care organization have been exhausted;
(b)A statement that the provider is entitled to an external independent third-party
review; and
(c)The time period and address to request an external independent third-party
review.
(4)A Medicaid managed care organization or provider shall be entitled to appeal a
final decision of the external independent third-party review to the Office of
Administrative Hearings within the Department of Law for an administrative
hearing to be held in accordance with KRS Chapter 13B. An appeal shall be filed
within thirty
(30)days from the appealing party's receipt of the final decision of the
external independent third-party review. A decision of the Office of Administrative
Hearings within the Department of Law shall be final for purposes of judicial
appeal. Any appeal of a final decision of an external independent third-party review
involving the submission of multiple claims as allowed under subsection
(2)of this
section shall be conducted as a single administrative hearing under this subsection.
(5)The department shall promulgate administrative regulations to implement the
external independent third-party review as required by this section.
(6)The department shall promulgate administrative regulations to establish reasonable
fees, not to exceed one thousand dollars ($1,000), to defray expenses associated
with an administrative hearing that shall be paid by the party who does not prevail
in the administrative hearing. If the administrative hearing is an appeal of a final
decision of an external independent third-party review involving the submission of
multiple claims as allowed under subsection
(2)of this section, only one
(1)fee
shall be assessed under this subsection against the party who does not prevail.
(7)This section shall apply to all contracts or master agreements between Medicaid
managed care organizations and the Commonwealth of Kentucky entered into or
renewed on or after July 1, 2016.