House File 766 S-3250 Amend the amendment, S-3201, to House File 766, as amended, 1 passed, and reprinted by the House, as follows: 2 1. Page 88, after line 7 by inserting: 3 < DIVISION ___ 4 PROVIDER APPEALS PROCESS —— EXTERNAL REVIEW 5 Sec. ___. MEDICAID MANAGED CARE ORGANIZATION APPEALS 6 PROCESS —— EXTERNAL REVIEW. 7 1. a. A Medicaid managed care organization under contract 8 with the state shall include in any written response to 9 a Medicaid provider under contract with the managed care 10 organization that reflects a final adverse determination of the 11 managed care organization’s internal appeal process relative to 12 an appeal filed by the Medicaid provider, all of the following: 13 (1) A statement that the Medicaid provider’s internal 14 appeal rights within the managed care organization have been 15 exhausted. 16 (2) A statement that the Medicaid provider is entitled to 17 an external independent third-party review pursuant to this 18 section. 19 (3) The requirements for requesting an external independent 20 third-party review. 21 b. If a managed care organization’s written response does 22 not comply with the requirements of paragraph “a”, the managed 23 care organization shall pay to the affected Medicaid provider a 24 penalty not to exceed one thousand dollars. 25 2. a. A Medicaid provider who has been denied the provision 26 of a service to a Medicaid member or a claim for reimbursement 27 for a service rendered to a Medicaid member, and who has 28 exhausted the internal appeals process of a managed care 29 organization, shall be entitled to an external independent 30 third-party review of the managed care organization’s final 31 adverse determination. 32 b. To request an external independent third-party review of 33 a final adverse determination by a managed care organization, 34 an aggrieved Medicaid provider shall submit a written request 35 -1- S3201.2359 (2) 88 pf/rn 1/ 5 #1.
for such review to the managed care organization within sixty 1 calendar days of receiving the final adverse determination. 2 c. A Medicaid provider’s request for such review shall 3 include all of the following: 4 (1) Identification of each specific issue and dispute 5 directly related to the final adverse determination issued by 6 the managed care organization. 7 (2) A statement of the basis upon which the Medicaid 8 provider believes the managed care organization’s determination 9 to be erroneous. 10 (3) The Medicaid provider’s designated contact information, 11 including name, mailing address, phone number, fax number, and 12 email address. 13 3. a. Within five business days of receiving a Medicaid 14 provider’s request for review pursuant to this subsection, the 15 managed care organization shall do all of the following: 16 (1) Confirm to the Medicaid provider’s designated contact, 17 in writing, that the managed care organization has received the 18 request for review. 19 (2) Notify the department of the Medicaid provider’s 20 request for review. 21 (3) Notify the affected Medicaid member of the Medicaid 22 provider’s request for review, if the review is related to the 23 denial of a service. 24 b. If the managed care organization fails to satisfy the 25 requirements of this subsection 3, the Medicaid provider shall 26 automatically prevail in the review. 27 4. a. Within fifteen calendar days of receiving a Medicaid 28 provider’s request for external independent third-party review, 29 the managed care organization shall do all of the following: 30 (1) Submit to the department all documentation submitted 31 by the Medicaid provider in the course of the managed care 32 organization’s internal appeal process. 33 (2) Provide the managed care organization’s designated 34 contact information, including name, mailing address, phone 35 -2- S3201.2359 (2) 88 pf/rn 2/ 5
number, fax number, and email address. 1 b. If a managed care organization fails to satisfy the 2 requirements of this subsection 4, the Medicaid provider shall 3 automatically prevail in the review. 4 5. An external independent third-party review shall 5 automatically extend the deadline to file an appeal for a 6 contested case hearing under chapter 17A, pending the outcome 7 of the external independent third-party review, until thirty 8 calendar days following receipt of the review decision by the 9 Medicaid provider. 10 6. Upon receiving notification of a request for external 11 independent third-party review, the department shall do all of 12 the following: 13 a. Assign the review to an external independent third-party 14 reviewer. 15 b. Notify the managed care organization of the identity of 16 the external independent third-party reviewer. 17 c. Notify the Medicaid provider’s designated contact of the 18 identity of the external independent third-party reviewer. 19 7. The department shall deny a request for an external 20 independent third-party review if the requesting Medicaid 21 provider fails to exhaust the managed care organization’s 22 internal appeals process or fails to submit a timely request 23 for an external independent third-party review pursuant to this 24 subsection. 25 8. a. Multiple appeals through the external independent 26 third-party review process regarding the same Medicaid 27 member, a common question of fact, or interpretation of common 28 applicable regulations or reimbursement requirements may 29 be combined and determined in one action upon request of a 30 party in accordance with rules and regulations adopted by the 31 department. 32 b. The Medicaid provider that initiated a request for 33 an external independent third-party review, or one or more 34 other Medicaid providers, may add claims to such an existing 35 -3- S3201.2359 (2) 88 pf/rn 3/ 5
external independent third-party review following exhaustion 1 of any applicable managed care organization internal appeals 2 process, if the claims involve a common question of fact 3 or interpretation of common applicable regulations or 4 reimbursement requirements. 5 9. Documentation reviewed by the external independent 6 third-party reviewer shall be limited to documentation 7 submitted pursuant to subsection 4. 8 10. An external independent third-party reviewer shall do 9 all of the following: 10 a. Conduct an external independent third-party review 11 of any claim submitted to the reviewer pursuant to this 12 subsection. 13 b. Within thirty calendar days from receiving the request 14 for review from the department and the documentation submitted 15 pursuant to subsection 4, issue the reviewer’s final decision 16 to the Medicaid provider’s designated contact, the managed 17 care organization’s designated contact, the department, and 18 the affected Medicaid member if the decision involves a denial 19 of service. The reviewer may extend the time to issue a final 20 decision by fourteen calendar days upon agreement of all 21 parties to the review. 22 11. The department shall enter into a contract with 23 an independent review organization that does not have a 24 conflict of interest with the department or any managed care 25 organization to conduct the independent third-party reviews 26 under this section. 27 a. A party, including the affected Medicaid member or 28 Medicaid provider, may appeal a final decision of the external 29 independent third-party reviewer in a contested case proceeding 30 in accordance with chapter 17A within thirty calendar days from 31 receiving the final decision. A final decision in a contested 32 case proceeding is subject to judicial review. 33 b. The final decision of any external independent 34 third-party review conducted pursuant to this subsection shall 35 -4- S3201.2359 (2) 88 pf/rn 4/ 5
also direct the nonprevailing party to pay an amount equal to 1 the costs of the review to the external independent third-party 2 reviewer. Any payment ordered pursuant to this subsection 3 shall be stayed pending any appeal of the review. If the 4 final outcome of any appeal is to reverse the decision of the 5 external independent third-party review, the nonprevailing 6 party shall pay the costs of the review to the external 7 independent third-party reviewer within forty-five calendar 8 days of entry of the final order. > 9 2. By renumbering as necessary. 10 ______________________________ LIZ MATHIS ______________________________ AMANDA RAGAN -5- S3201.2359 (2) 88 pf/rn 5/ 5 #2.