Senate File 334 S-3087 Amend Senate File 334 as follows: 1 1. Page 1, before line 1 by inserting: 2 < DIVISION I 3 PUBLIC ASSISTANCE PROGRAM ACCOUNTABILITY —— ELIGIBILITY 4 VERIFICATION AND MONITORING > 5 2. Page 5, line 5, after < this > by inserting < division of 6 this > 7 3. Page 5, line 11, after < this > by inserting < division of 8 this > 9 4. Page 5, line 23, by striking < the Act > and inserting 10 < this division of this Act > 11 5. Page 5, by striking line 28 and inserting < this division 12 of this Act. > 13 6. Page 5, line 30, after < this > by inserting < division of 14 this > 15 7. Page 5, line 33, after < this > by inserting < division of 16 this > 17 8. Page 5, after line 35 by inserting: 18 < DIVISION ___ 19 PUBLIC ASSISTANCE PROGRAM ACCOUNTABILITY —— MEDICAID MANAGED 20 CARE EXTERNAL REVIEW 21 Sec. ___. MEDICAID MANAGED CARE ORGANIZATION APPEALS 22 PROCESS —— EXTERNAL REVIEW. 23 1. a. A Medicaid managed care organization under contract 24 with the state shall include in any written response to 25 a Medicaid provider under contract with the managed care 26 organization that reflects a final adverse determination of the 27 managed care organization’s internal appeal process relative to 28 an appeal filed by the Medicaid provider, all of the following: 29 (1) A statement that the Medicaid provider’s internal 30 appeal rights within the managed care organization have been 31 exhausted. 32 (2) A statement that the Medicaid provider is entitled to 33 an external independent third-party review pursuant to this 34 section. 35 -1- SF334.1275 (1) 88 pf/rh 1/ 6 #1. #2. #3. #4. #5. #6. #7. #8.

(3) The requirements for requesting an external independent 1 third-party review. 2 b. If a managed care organization’s written response does 3 not comply with the requirements of paragraph “a”, the managed 4 care organization shall pay to the affected Medicaid provider a 5 penalty not to exceed one thousand dollars. 6 2. a. A Medicaid provider who has been denied the provision 7 of a service to a Medicaid member or a claim for reimbursement 8 for a service rendered to a Medicaid member, and who has 9 exhausted the internal appeals process of a managed care 10 organization, shall be entitled to an external independent 11 third-party review of the managed care organization’s final 12 adverse determination. 13 b. To request an external independent third-party review of 14 a final adverse determination by a managed care organization, 15 an aggrieved Medicaid provider shall submit a written request 16 for such review to the managed care organization within sixty 17 calendar days of receiving the final adverse determination. 18 c. A Medicaid provider’s request for such review shall 19 include all of the following: 20 (1) Identification of each specific issue and dispute 21 directly related to the final adverse determination issued by 22 the managed care organization. 23 (2) A statement of the basis upon which the Medicaid 24 provider believes the managed care organization’s determination 25 to be erroneous. 26 (3) The Medicaid provider’s designated contact information, 27 including name, mailing address, phone number, fax number, and 28 email address. 29 3. a. Within five business days of receiving a Medicaid 30 provider’s request for review pursuant to this subsection, the 31 managed care organization shall do all of the following: 32 (1) Confirm to the Medicaid provider’s designated contact, 33 in writing, that the managed care organization has received the 34 request for review. 35 -2- SF334.1275 (1) 88 pf/rh 2/ 6

(2) Notify the department of the Medicaid provider’s 1 request for review. 2 (3) Notify the affected Medicaid member of the Medicaid 3 provider’s request for review, if the review is related to the 4 denial of a service. 5 b. If the managed care organization fails to satisfy the 6 requirements of this subsection 3, the Medicaid provider shall 7 automatically prevail in the review. 8 4. a. Within fifteen calendar days of receiving a Medicaid 9 provider’s request for external independent third-party review, 10 the managed care organization shall do all of the following: 11 (1) Submit to the department all documentation submitted 12 by the Medicaid provider in the course of the managed care 13 organization’s internal appeal process. 14 (2) Provide the managed care organization’s designated 15 contact information, including name, mailing address, phone 16 number, fax number, and email address. 17 b. If a managed care organization fails to satisfy the 18 requirements of this subsection 4, the Medicaid provider shall 19 automatically prevail in the review. 20 5. An external independent third-party review shall 21 automatically extend the deadline to file an appeal for a 22 contested case hearing under chapter 17A, pending the outcome 23 of the external independent third-party review, until thirty 24 calendar days following receipt of the review decision by the 25 Medicaid provider. 26 6. Upon receiving notification of a request for external 27 independent third-party review, the department shall do all of 28 the following: 29 a. Assign the review to an external independent third-party 30 reviewer. 31 b. Notify the managed care organization of the identity of 32 the external independent third-party reviewer. 33 c. Notify the Medicaid provider’s designated contact of the 34 identity of the external independent third-party reviewer. 35 -3- SF334.1275 (1) 88 pf/rh 3/ 6

7. The department shall deny a request for an external 1 independent third-party review if the requesting Medicaid 2 provider fails to exhaust the managed care organization’s 3 internal appeals process or fails to submit a timely request 4 for an external independent third-party review pursuant to this 5 subsection. 6 8. a. Multiple appeals through the external independent 7 third-party review process regarding the same Medicaid 8 member, a common question of fact, or interpretation of common 9 applicable regulations or reimbursement requirements may 10 be combined and determined in one action upon request of a 11 party in accordance with rules and regulations adopted by the 12 department. 13 b. The Medicaid provider that initiated a request for 14 an external independent third-party review, or one or more 15 other Medicaid providers, may add claims to such an existing 16 external independent third-party review following exhaustion 17 of any applicable managed care organization internal appeals 18 process, if the claims involve a common question of fact 19 or interpretation of common applicable regulations or 20 reimbursement requirements. 21 9. Documentation reviewed by the external independent 22 third-party reviewer shall be limited to documentation 23 submitted pursuant to subsection 4. 24 10. An external independent third-party reviewer shall do 25 all of the following: 26 a. Conduct an external independent third-party review 27 of any claim submitted to the reviewer pursuant to this 28 subsection. 29 b. Within thirty calendar days from receiving the request 30 for review from the department and the documentation submitted 31 pursuant to subsection 4, issue the reviewer’s final decision 32 to the Medicaid provider’s designated contact, the managed 33 care organization’s designated contact, the department, and 34 the affected Medicaid member if the decision involves a denial 35 -4- SF334.1275 (1) 88 pf/rh 4/ 6

of service. The reviewer may extend the time to issue a final 1 decision by fourteen calendar days upon agreement of all 2 parties to the review. 3 11. The department shall enter into a contract with 4 an independent review organization that does not have a 5 conflict of interest with the department or any managed care 6 organization to conduct the independent third-party reviews 7 under this section. 8 a. A party, including the affected Medicaid member or 9 Medicaid provider, may appeal a final decision of the external 10 independent third-party reviewer in a contested case proceeding 11 in accordance with chapter 17A within thirty calendar days from 12 receiving the final decision. A final decision in a contested 13 case proceeding is subject to judicial review. 14 b. The final decision of any external independent 15 third-party review conducted pursuant to this subsection shall 16 also direct the nonprevailing party to pay an amount equal to 17 the costs of the review to the external independent third-party 18 reviewer. Any payment ordered pursuant to this subsection 19 shall be stayed pending any appeal of the review. If the 20 final outcome of any appeal is to reverse the decision of the 21 external independent third-party review, the nonprevailing 22 party shall pay the costs of the review to the external 23 independent third-party reviewer within forty-five calendar 24 days of entry of the final order. 25 DIVISION ___ 26 PUBLIC ASSISTANCE PROGRAM ACCOUNTABILITY —— MEDICAID PROGRAM 27 CONSUMER PROTECTION 28 Sec. ___. NEW SECTION . 2C.6A Assistant for Medicaid 29 program. 30 1. The ombudsman shall appoint an assistant who shall be 31 primarily responsible for investigating complaints relating to 32 the Medicaid program, including both Medicaid fee-for-service 33 and managed care payment and delivery systems, and all Medicaid 34 populations including the long-term services and supports 35 -5- SF334.1275 (1) 88 pf/rh 5/ 6

population. 1 2. The ombudsman shall provide assistance and advocacy 2 services to Medicaid recipients and the families or legal 3 representatives of Medicaid recipients. Such assistance 4 and advocacy shall include but is not limited to all of the 5 following: 6 a. Assisting recipients in understanding the services, 7 coverage, and access provisions and their rights under the 8 Medicaid program. 9 b. Developing procedures for the tracking and reporting 10 of the outcomes of individual requests for assistance, the 11 procedures available for obtaining services, and other aspects 12 of the services provided to Medicaid recipients. 13 c. Providing advice and assistance relating to the 14 preparation and filing of complaints, grievances, and appeals 15 of complaints or grievances, including through processes 16 available under managed care plans and the state appeals 17 process under the Medicaid program. 18 3. The ombudsman shall adopt rules to administer this 19 section. 20 4. The ombudsman shall publish special reports and 21 investigative reports as deemed necessary and shall include 22 findings and recommendations related to the assistance and 23 advocacy provided under this section in the ombudsman’s annual 24 report. 25 Sec. ___. REPEAL. Section 231.44, Code 2019, is repealed. > 26 9. By renumbering as necessary. 27 ______________________________ LIZ MATHIS ______________________________ AMANDA RAGAN -6- SF334.1275 (1) 88 pf/rh 6/ 6 #9.