S.F. 211 Section 1. MEDICAID MANAGED CARE —— EXTERNAL REVIEW OF 1 PROVIDER APPEALS. 2 1. a. A Medicaid managed care organization under contract 3 with the state shall include in any written response to 4 a Medicaid provider under contract with the managed care 5 organization that reflects a final adverse determination of the 6 managed care organization’s internal appeal process relative to 7 an appeal filed by the Medicaid provider, all of the following: 8 (1) A statement that the Medicaid provider’s internal 9 appeal rights within the managed care organization have been 10 exhausted. 11 (2) A statement that the Medicaid provider is entitled to 12 an external independent third-party review pursuant to this 13 section. 14 (3) The requirements for requesting an external independent 15 third-party review. 16 b. If a managed care organization’s written response does 17 not comply with the requirements of paragraph “a”, the managed 18 care organization shall pay to the affected Medicaid provider a 19 penalty not to exceed one thousand dollars. 20 2. a. A Medicaid provider who has been denied the provision 21 of a service to a Medicaid member or a claim for reimbursement 22 for a service rendered to a Medicaid member, and who has 23 exhausted the internal appeals process of a managed care 24 organization, shall be entitled to an external independent 25 third-party review of the managed care organization’s final 26 adverse determination. 27 b. To request an external independent third-party review of 28 a final adverse determination by a managed care organization, 29 an aggrieved Medicaid provider shall submit a written request 30 for such review to the managed care organization within sixty 31 calendar days of receiving the final adverse determination. 32 c. A Medicaid provider’s request for such review shall 33 include all of the following: 34 (1) Identification of each specific issue and dispute 35 -1- LSB 1964XS (4) 88 pf/rh 1/ 5

S.F. 211 directly related to the final adverse determination issued by 1 the managed care organization. 2 (2) A statement of the basis upon which the Medicaid 3 provider believes the managed care organization’s determination 4 to be erroneous. 5 (3) The Medicaid provider’s designated contact information, 6 including name, mailing address, phone number, fax number, and 7 email address. 8 3. a. Within five business days of receiving a Medicaid 9 provider’s request for review pursuant to this subsection, the 10 managed care organization shall do all of the following: 11 (1) Confirm to the Medicaid provider’s designated contact, 12 in writing, that the managed care organization has received the 13 request for review. 14 (2) Notify the department of the Medicaid provider’s 15 request for review. 16 (3) Notify the affected Medicaid member of the Medicaid 17 provider’s request for review, if the review is related to the 18 denial of a service. 19 b. If the managed care organization fails to satisfy the 20 requirements of this subsection 3, the Medicaid provider shall 21 automatically prevail in the review. 22 4. a. Within fifteen calendar days of receiving a Medicaid 23 provider’s request for external independent third-party review, 24 the managed care organization shall do all of the following: 25 (1) Submit to the department all documentation submitted 26 by the Medicaid provider in the course of the managed care 27 organization’s internal appeal process. 28 (2) Provide the managed care organization’s designated 29 contact information, including name, mailing address, phone 30 number, fax number, and email address. 31 b. If a managed care organization fails to satisfy the 32 requirements of this subsection 4, the Medicaid provider shall 33 automatically prevail in the review. 34 5. An external independent third-party review shall 35 -2- LSB 1964XS (4) 88 pf/rh 2/ 5

S.F. 211 automatically extend the deadline to file an appeal for a 1 contested case hearing under chapter 17A, pending the outcome 2 of the external independent third-party review, until thirty 3 calendar days following receipt of the review decision by the 4 Medicaid provider. 5 6. Upon receiving notification of a request for external 6 independent third-party review, the department shall do all of 7 the following: 8 a. Assign the review to an external independent third-party 9 reviewer. 10 b. Notify the managed care organization of the identity of 11 the external independent third-party reviewer. 12 c. Notify the Medicaid provider’s designated contact of the 13 identity of the external independent third-party reviewer. 14 7. The department shall deny a request for an external 15 independent third-party review if the requesting Medicaid 16 provider fails to exhaust the managed care organization’s 17 internal appeals process or fails to submit a timely request 18 for an external independent third-party review pursuant to this 19 subsection. 20 8. a. Multiple appeals through the external independent 21 third-party review process regarding the same Medicaid 22 member, a common question of fact, or interpretation of common 23 applicable regulations or reimbursement requirements may 24 be combined and determined in one action upon request of a 25 party in accordance with rules and regulations adopted by the 26 department. 27 b. The Medicaid provider that initiated a request for 28 an external independent third-party review, or one or more 29 other Medicaid providers, may add claims to such an existing 30 external independent third-party review following exhaustion 31 of any applicable managed care organization internal appeals 32 process, if the claims involve a common question of fact 33 or interpretation of common applicable regulations or 34 reimbursement requirements. 35 -3- LSB 1964XS (4) 88 pf/rh 3/ 5

S.F. 211 9. Documentation reviewed by the external independent 1 third-party reviewer shall be limited to documentation 2 submitted pursuant to subsection 4. 3 10. An external independent third-party reviewer shall do 4 all of the following: 5 a. Conduct an external independent third-party review 6 of any claim submitted to the reviewer pursuant to this 7 subsection. 8 b. Within thirty calendar days from receiving the request 9 for review from the department and the documentation submitted 10 pursuant to subsection 4, issue the reviewer’s final decision 11 to the Medicaid provider’s designated contact, the managed 12 care organization’s designated contact, the department, and 13 the affected Medicaid member if the decision involves a denial 14 of service. The reviewer may extend the time to issue a final 15 decision by fourteen calendar days upon agreement of all 16 parties to the review. 17 11. The department shall enter into a contract with 18 an independent review organization that does not have a 19 conflict of interest with the department or any managed care 20 organization to conduct the independent third-party reviews 21 under this section. 22 a. A party, including the affected Medicaid member or 23 Medicaid provider, may appeal a final decision of the external 24 independent third-party reviewer in a contested case proceeding 25 in accordance with chapter 17A within thirty calendar days from 26 receiving the final decision. A final decision in a contested 27 case proceeding is subject to judicial review. 28 b. The final decision of any external independent 29 third-party review conducted pursuant to this subsection shall 30 also direct the nonprevailing party to pay an amount equal to 31 the costs of the review to the external independent third-party 32 reviewer. Any payment ordered pursuant to this subsection 33 shall be stayed pending any appeal of the review. If the 34 final outcome of any appeal is to reverse the decision of the 35 -4- LSB 1964XS (4) 88 pf/rh 4/ 5

S.F. 211 external independent third-party review, the nonprevailing 1 party shall pay the costs of the review to the external 2 independent third-party reviewer within forty-five calendar 3 days of entry of the final order. 4 EXPLANATION 5 The inclusion of this explanation does not constitute agreement with 6 the explanation’s substance by the members of the general assembly. 7 This bill establishes an external review process 8 for Medicaid providers for the review of final adverse 9 determinations of a Medicaid managed care organization’s 10 (MCO’s) internal appeal processes. The external review 11 process would be available to a Medicaid provider who has been 12 denied the provision of services to a Medicaid member or a 13 claim for reimbursement, and who has exhausted the internal 14 appeals process of an MCO. The bill specifies the process 15 for the external review and provides that a final decision 16 of an external reviewer may be reviewed in a contested case 17 proceeding pursuant to Code chapter 17A, and is ultimately 18 subject to judicial review. 19 -5- LSB 1964XS (4) 88 pf/rh 5/ 5