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
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#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
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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
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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
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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
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5
#2.