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
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#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:
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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
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______________________________
HEATON
of
Henry
______________________________
FRY
of
Clarke
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4