S.F. _____ DIVISION I 1 MEDICAID STREAMLINED PROCESSES AND OVERSIGHT 2 Section 1. MEDICAID STREAMLINED PROCESSES AND 3 OVERSIGHT. The department of human services shall provide 4 for the streamlining of and consistency in Medicaid program 5 processes and procedures as follows: 6 1. That for both fee-for-service and managed care 7 administration, prior authorization requirements shall be 8 based on those established by the Iowa Medicaid enterprise 9 and that resources shall be available twenty-four hours per 10 day, three hundred sixty-five days per year to evaluate prior 11 authorization requests and avoid delays in the provision of 12 medically necessary care and services. 13 2. That all Medicaid managed care organizations under 14 contract with the state utilize uniform payment authorization 15 criteria and comply with contract provisions related to timely 16 payment. 17 3. That all Medicaid managed care organizations contracting 18 with the state post a complete and accurate roster of the 19 managed care organization’s participating providers and update 20 the roster in a timely manner to ensure an accurate roster of 21 in-network providers to facilitate service and care referrals 22 and appropriate discharge of members. 23 4. That all Medicaid managed care organizations contracting 24 with the state provide the Medicaid managed care organization’s 25 participating providers with the functionality to submit and 26 track all claims, claim disputes, claim reconsiderations, and 27 appeals on the Medicaid managed care organization’s website to 28 facilitate participation in an open and shared provider record. 29 5. That all Medicaid managed care organizations contracting 30 with the state provide uniform benefits to eliminate 31 disparities and provide consistent coverage to Medicaid members 32 across all Medicaid managed care organizations. 33 DIVISION II 34 MEDICAID CREDENTIALING PROVISIONS 35 -1- LSB 2752XC (4) 88 pf/rh 1/ 8

S.F. _____ Sec. 2. MEDICAID PROGRAM —— USE OF UNIFORM AUTHORIZATION 1 CRITERIA AND SINGLE CREDENTIALING VERIFICATION 2 ORGANIZATION. The department of human services shall 3 develop uniform authorization criteria for, and shall 4 utilize a request for proposals process to procure a single 5 credentialing verification organization to be utilized by 6 the state in credentialing and recredentialing providers for 7 both the Medicaid managed care and fee-for-service payment and 8 delivery systems. The department shall contractually require 9 all Medicaid managed care organizations to apply the uniform 10 authorization criteria, to accept verified information from the 11 single credentialing verification organization procured by the 12 state, and to approve or deny a provider’s credentials within 13 sixty days of receipt of the request for approval, and shall 14 contractually prohibit Medicaid managed care organizations 15 from requiring additional credentialing information from a 16 provider in order to participate in the Medicaid managed care 17 organization’s provider network. 18 DIVISION III 19 MEDICAID MANAGED CARE APPEALS —— INTERNAL AND EXTERNAL REVIEW 20 Sec. 3. MEDICAID MANAGED CARE APPEALS —— INTERNAL APPEAL 21 PROCESS AND EXTERNAL REVIEW. 22 1. A Medicaid managed care organization contracting with 23 the state shall provide an internal appeal process for a 24 Medicaid provider who has been denied a claim for the provision 25 of a service to a Medicaid member or a claim for reimbursement 26 for a service rendered to a Medicaid member. All forms, 27 processes, and communications involved in the internal appeal 28 process shall be uniform across all Medicaid managed care 29 organizations. The internal appeal process shall provide for 30 all of the following: 31 a. The Medicaid provider’s written request for an internal 32 appeal shall include identification of the Medicaid payment 33 policy in support of the provider’s claim, each specific issue 34 and dispute directly related to the claim, and a statement of 35 -2- LSB 2752XC (4) 88 pf/rh 2/ 8

S.F. _____ the basis upon which the Medicaid provider believes the managed 1 care organization’s determination to be erroneous. 2 b. Within fifteen days of receipt of a written request 3 from a Medicaid provider for an internal appeal of a Medicaid 4 managed care organization’s decision, an independent third 5 party shall hold a hearing on the claim in accordance with 6 Medicaid program rules and written policies and the Medicaid 7 state plan. The independent third party shall render a 8 decision within fifteen days of completion of the hearing. The 9 department of human services shall provide guidance to the 10 Medicaid provider and the Medicaid managed care organization 11 regarding any ambiguity in the rules, written policies, or 12 Medicaid state plan to facilitate the appeal process. 13 c. If the internal appeal process results in a final adverse 14 determination for the Medicaid provider, the Medicaid provider 15 may request an external independent third-party review as 16 provided in this section. 17 2. A Medicaid managed care organization under contract with 18 the state shall include in any written response to a Medicaid 19 provider under contract with the managed care organization that 20 reflects a final adverse determination of the managed care 21 organization’s internal appeal process relative to an appeal 22 filed by the Medicaid provider, all of the following: 23 a. A statement that the Medicaid provider’s internal 24 appeal rights within the managed care organization have been 25 exhausted. 26 b. A statement that the Medicaid provider is entitled to 27 an external independent third-party review pursuant to this 28 section. 29 c. The requirements for requesting an external independent 30 third-party review. 31 3. a. A Medicaid provider who has been denied the provision 32 of a service to a Medicaid member or a claim for reimbursement 33 for a service rendered to a Medicaid member, and who has 34 exhausted the internal appeals process of a managed care 35 -3- LSB 2752XC (4) 88 pf/rh 3/ 8

S.F. _____ organization, shall be entitled to an external independent 1 third-party review of the managed care organization’s final 2 adverse determination. 3 b. To request an external independent third-party review of 4 a final adverse determination by a managed care organization, 5 an aggrieved Medicaid provider shall submit a written request 6 for such review to the managed care organization within sixty 7 calendar days of receiving the final adverse determination. 8 c. A Medicaid provider’s request for such review shall 9 include all of the following: 10 (1) Identification of each specific issue and dispute 11 directly related to the final adverse determination issued by 12 the managed care organization. 13 (2) A statement of the basis upon which the Medicaid 14 provider believes the managed care organization’s determination 15 to be erroneous. 16 (3) The Medicaid provider’s designated contact information, 17 including name, mailing address, phone number, fax number, and 18 email address. 19 4. a. Within five business days of receiving a Medicaid 20 provider’s request for review pursuant to this subsection, the 21 managed care organization shall do all of the following: 22 (1) Confirm to the Medicaid provider’s designated contact, 23 in writing, that the managed care organization has received the 24 request for review. 25 (2) Notify the department of the Medicaid provider’s 26 request for review. 27 (3) Notify the affected Medicaid member of the Medicaid 28 provider’s request for review, if the review is related to the 29 denial of a service. 30 b. If the managed care organization fails to satisfy the 31 requirements of this subsection 4, the Medicaid provider shall 32 automatically prevail in the review. 33 5. a. Within fifteen calendar days of receiving a Medicaid 34 provider’s request for external independent third-party review, 35 -4- LSB 2752XC (4) 88 pf/rh 4/ 8

S.F. _____ the managed care organization shall do all of the following: 1 (1) Submit to the department all documentation submitted 2 by the Medicaid provider in the course of the managed care 3 organization’s internal appeal process. 4 (2) Provide the managed care organization’s designated 5 contact information, including name, mailing address, phone 6 number, fax number, and email address. 7 b. If a managed care organization fails to satisfy the 8 requirements of this subsection 5, the Medicaid provider shall 9 automatically prevail in the review. 10 6. An external independent third-party review shall 11 automatically extend the deadline to file an appeal for a 12 contested case hearing under chapter 17A, pending the outcome 13 of the external independent third-party review, until thirty 14 calendar days following receipt of the review decision by the 15 Medicaid provider. 16 7. Upon receiving notification of a request for external 17 independent third-party review, the department shall do all of 18 the following: 19 a. Assign the review to an external independent third-party 20 reviewer. 21 b. Notify the managed care organization of the identity of 22 the external independent third-party reviewer. 23 c. Notify the Medicaid provider’s designated contact of the 24 identity of the external independent third-party reviewer. 25 8. The department shall deny a request for an external 26 independent third-party review if the requesting Medicaid 27 provider fails to exhaust the managed care organization’s 28 internal appeals process or fails to submit a timely request 29 for an external independent third-party review pursuant to this 30 subsection. 31 9. a. Multiple appeals through the external independent 32 third-party review process regarding the same Medicaid 33 member, a common question of fact, or interpretation of common 34 applicable regulations or reimbursement requirements may 35 -5- LSB 2752XC (4) 88 pf/rh 5/ 8

S.F. _____ be combined and determined in one action upon request of a 1 party in accordance with rules and regulations adopted by the 2 department. 3 b. The Medicaid provider that initiated a request for 4 an external independent third-party review, or one or more 5 other Medicaid providers, may add claims to such an existing 6 external independent third-party review following exhaustion 7 of any applicable managed care organization internal appeals 8 process, if the claims involve a common question of fact 9 or interpretation of common applicable regulations or 10 reimbursement requirements. 11 10. Documentation reviewed by the external independent 12 third-party reviewer shall be limited to documentation 13 submitted pursuant to subsection 5. 14 11. An external independent third-party reviewer shall do 15 all of the following: 16 a. Conduct an external independent third-party review 17 of any claim submitted to the reviewer pursuant to this 18 subsection. 19 b. Within forty-five calendar days from receiving the 20 request for review from the department and the documentation 21 submitted pursuant to subsection 5, issue the reviewer’s final 22 decision to the Medicaid provider’s designated contact, the 23 managed care organization’s designated contact, the department, 24 and the affected Medicaid member if the decision involves a 25 denial of service. The reviewer may extend the time to issue a 26 final decision by fourteen calendar days upon agreement of all 27 parties to the review. 28 12. The department shall enter into a contract with 29 an independent review organization that does not have a 30 conflict of interest with the department or any managed care 31 organization to conduct the independent third-party reviews 32 under this section. 33 a. A party, including the affected Medicaid member or 34 Medicaid provider, may appeal a final decision of the external 35 -6- LSB 2752XC (4) 88 pf/rh 6/ 8

S.F. _____ independent third-party reviewer in a contested case proceeding 1 in accordance with chapter 17A within thirty calendar days from 2 receiving the final decision. A final decision in a contested 3 case proceeding is subject to judicial review. 4 b. The final decision of any external independent 5 third-party review conducted pursuant to this subsection shall 6 also direct the nonprevailing party to pay an amount equal to 7 the costs of the review to the external independent third-party 8 reviewer. Any payment ordered pursuant to this subsection 9 shall be stayed pending any appeal of the review. If the 10 final outcome of any appeal is to reverse the decision of the 11 external independent third-party review, the nonprevailing 12 party shall pay the costs of the review to the external 13 independent third-party reviewer within forty-five calendar 14 days of entry of the final order. 15 EXPLANATION 16 The inclusion of this explanation does not constitute agreement with 17 the explanation’s substance by the members of the general assembly. 18 This bill relates to Medicaid processes, procedures, and 19 oversight. 20 Division I of the bill provides for streamlined processes 21 and oversight under the Medicaid program. The bill requires 22 the department of human services (DHS) to provide for the 23 streamlining of and consistency in Medicaid program processes 24 and procedures relating to prior authorization requirements; 25 utilization of uniform payment authorization criteria and 26 compliance with contract provisions related to timely payment; 27 the posting and updating of a complete and accurate roster of a 28 Medicaid managed care organization’s participating providers; 29 the submission and tracking of claims, claims disputes, claims 30 reconsiderations, and appeals on the Medicaid managed care 31 organization’s website; and the provision of uniform benefits 32 across all Medicaid managed care organizations. 33 Division II of the bill requires DHS to develop uniform 34 authorization criteria for, and to utilize a request 35 -7- LSB 2752XC (4) 88 pf/rh 7/ 8

S.F. _____ for proposals process to procure a single credentialing 1 verification organization to be utilized in credentialing and 2 recredentialing providers for the Medicaid managed care and 3 fee-for-service payment and delivery systems. The division 4 requires DHS to contractually require all Medicaid managed care 5 organizations to apply the uniform authorization criteria, 6 to accept verified information from the single credentialing 7 verification organization procured by the state, to approve 8 or deny a provider’s application for credentialing within 9 60 days of submission for approval, and to contractually 10 prohibit the Medicaid managed care organizations from requiring 11 additional credentialing information from a provider in order 12 to participate in the Medicaid managed care organization’s 13 provider network. 14 Division III of the bill establishes internal and external 15 review processes for Medicaid providers for the review of 16 initial and final adverse determinations of the MCOs’ internal 17 appeal processes. The division provides that a final decision 18 of an external reviewer may be reviewed in a contested case 19 proceeding pursuant to Code chapter 17A, and ultimately is 20 subject to judicial review. 21 -8- LSB 2752XC (4) 88 pf/rh 8/ 8