House File 2462 H-8220 Amend House File 2462 as follows: 1 1. By striking page 2, line 35, through page 3, line 3, and 2 inserting: 3 < Sec. ___. MEDICAID PROGRAM ADMINISTRATION. 4 1. PROVIDER PROCESSES AND PROCEDURES. 5 a. When all of the required documents and other information 6 necessary to process a claim have been received by a managed 7 care organization, the managed care organization shall 8 either provide payment to the claimant within the timelines 9 specified in the managed care contract or, if the managed 10 care organization is denying the claim in whole or in part, 11 shall provide notice to the claimant including the reasons for 12 such denial consistent with national industry best practice 13 guidelines. 14 b. If a managed care organization discovers that a claims 15 payment barrier is the result of a managed care organization’s 16 identified system configuration error, the managed care 17 organization shall correct such error within ninety days of the 18 discovery of the error and shall fully and accurately reprocess 19 the claims affected by the error within thirty days of such 20 discovery. For the purposes of this paragraph, “configuration 21 error” means an error in provider data, an incorrect fee 22 schedule, or an incorrect claims edit. 23 c. The department of human services shall provide for 24 the development and require the use of standardized Medicaid 25 provider enrollment forms to be used by the department and 26 uniform Medicaid provider credentialing standards to be used 27 by managed care organizations. The credentialing process is 28 deemed to begin when the managed care organization has received 29 all necessary credentialing materials from the provider and is 30 deemed to have ended when written communication is mailed or 31 faxed to the provider notifying the provider of the managed 32 care organization’s decision. 33 2. MEMBER SERVICES AND PROCESSES. 34 a. If a Medicaid member prevails in a review by a managed 35 -1- HF2462.4238 (10) 87 pf/rh 1/ 4 #1.

care organization or on appeal regarding the provision 1 of services, the services subject to the review or appeal 2 shall be extended for a period of time determined by the 3 director of human services. However, services shall not be 4 extended if there is a change in the member’s condition that 5 warrants a change in services as determined by the member’s 6 interdisciplinary team, there is a change in the member’s 7 eligibility status as determined by the department of human 8 services, or the member voluntarily withdraws from services. 9 b. If a Medicaid member is receiving court-ordered services 10 or treatment, such services or treatment shall be provided 11 and reimbursed for an initial period of five days before a 12 managed care organization may apply medical necessity criteria 13 to determine the most appropriate services, treatment, or 14 placement for the Medicaid member. 15 c. The department of human services shall review and have 16 approval authority for a Medicaid member’s level of care 17 reassessment that indicates a decrease in the level of care. 18 A managed care organization shall comply with the findings of 19 the departmental review and approval of such level of care 20 reassessment. If a level of care reassessment indicates there 21 is no change in a Medicaid member’s level of care needs, the 22 Medicaid member’s existing level of care shall be continued. A 23 managed care organization shall maintain and make available to 24 the department of human services all documentation relating to 25 a Medicaid member’s level of care assessment. 26 d. The department of human services shall maintain and 27 update Medicaid member eligibility files in a timely manner 28 consistent with national industry best practices. 29 3. MEDICAID PROGRAM REVIEW AND OVERSIGHT. 30 a. (1) The department of human services shall facilitate a 31 workgroup, in collaboration with representatives of the managed 32 care organizations and health home providers, to review the 33 health home programs. The review shall include all of the 34 following: 35 -2- HF2462.4238 (10) 87 pf/rh 2/ 4

(a) An analysis of the state plan amendments applicable to 1 health homes. 2 (b) An analysis of the current health home system, including 3 the rationale for any recommended changes. 4 (c) The development of a clear and consistent delivery 5 model linked to program-determined outcomes and data reporting 6 requirements. 7 (d) A work plan to be used in communicating with 8 stakeholders regarding the administration and operation of the 9 health home programs. 10 (2) The department of human services shall submit a report 11 of the workgroup’s findings and recommendations by December 12 15, 2018, to the governor and to the Eighty-eighth General 13 Assembly, 2019 session, for consideration. 14 b. The department of human services, in collaboration 15 with Medicaid providers and managed care organizations, shall 16 initiate a review process to determine the effectiveness of 17 prior authorizations used by the managed care organizations 18 with the goal of making adjustments based on relevant 19 service costs and member outcomes data utilizing existing 20 industry-accepted standards. Prior authorization policies 21 shall comply with existing rules, guidelines, and procedures 22 developed by the centers for Medicare and Medicaid services of 23 the United States department of health and human services. 24 c. The department of human services shall enter into a 25 contract with an independent auditor to perform an audit of 26 small dollar claims paid to or denied Medicaid long-term 27 services and supports providers. The department may take any 28 action specified in the managed care contract relative to 29 any claim the auditor determines to be incorrectly paid or 30 denied, subject to appeal by the managed care organization 31 to the director of human services. For the purposes of this 32 paragraph, “small dollar claims” means those claims less than 33 or equal to two thousand five hundred dollars. > 34 2. By renumbering as necessary. 35 -3- HF2462.4238 (10) 87 pf/rh 3/ 4