Current through Register Vol. 50, No. 9, March 1, 2024
RELATES TO:
KRS
194A.025(3),
205.646,
42 C.F.R. 438
NECESSITY, FUNCTION, AND CONFORMITY: The Cabinet for Health and
Family Services, Department for Medicaid Services has responsibility to
administer the Medicaid Program.
KRS
205.520(3) authorizes the
cabinet, by administrative regulation, to comply with a requirement that may be
imposed or opportunity presented by federal law to qualify for federal Medicaid
funds.
KRS
205.646 entitles a party to appeal a final
decision of the external independent third-party review to the administrative
hearing tribunal within the Cabinet for Health and Family Services. This
administrative regulation establishes provisions regarding a Medi-caid
provider's and managed care organization's right to an administrative hearing
following an external independent third-party review.
Section 1. Administrative Hearing Notice and
Preliminary Requirements.
(1) Upon the
issuance of a final decision by an external independent third-party reviewer
pursuant to
907 KAR
17:035, the department shall notify in writing the MCO
and the provider of the right of the party that received an adverse final
decision to appeal the decision by requesting an administrative hearing
pursuant to this administrative regulation.
(2)
(a) A
written request for an administrative hearing referenced in subsection (1) of
this section shall be sent to the department within thirty (30) calendar days
of receipt of the department's written notice referenced in subsection (1) of
this section.
(b) The request for
an administrative hearing shall be sent to the department:
1. Electronically;
2. By fax; or
3. By postal mail.
(3) A provider or MCO request for
an administrative hearing shall:
(a) Identify
each specific issue and dispute directly related to the adverse final decision
issued by the external independent third-party reviewer;
(b) State the basis on which the external
independent third-party reviewer's decision on each issue is believed to be
erroneous;
(c) Limit disputes to
the information contained in the record on appeal, as required by
907 KAR
17:035, Section 2(7)(a), and any other information
contained in the external independent third-party reviewer's
decision;
(d) State the name,
mailing address, and telephone number of individuals who may be contacted about
the request for an administrative hearing; and
(e) State the mailing address, fax number,
email address, or other contact information to which the MCO's confirmation of
receipt of the request shall be sent.
(4) The department shall forward to the
hearing officer an administrative record on appeal that shall include:
(a) The notice of action taken;
(b) The statutory or regulatory basis for the
action taken;
(c) The decision
following the external independent third-party review; and
(d) The record on appeal as required by
907 KAR
17:035, Section 2(7)(a).
(5) The department shall deny a request to
initiate the administrative hearing appeal process, or a part thereof, if a
party fails to:
(a) Exhaust the external
independent third-party review process in accordance with
907 KAR
17:035; or
(b) Submit a timely request for
administrative hearing in accordance with subsection (2) of this
section.
Section
2. Administrative Hearing.
(1)
(a) A hearing officer shall establish the
date, time, and location of an administrative hearing.
(b) The administrative hearing shall be held
in Frankfort, Kentucky.
(c) The
hearing officer shall comply with the notice requirements established in
KRS
13B.050.
(d) An administrative hearing date shall be
scheduled to occur no later than sixty (60) calendar days from the date that
the administrative hearing request was received by the department.
(e) An administrative hearing date may be
extended beyond sixty (60) calendar days upon agreement of both
parties.
(2) If a
pre-hearing conference is requested by a party and granted by the hearing
officer, the conference shall comply with
KRS
13B.070.
(3) An administrative hearing may be
withdrawn if:
(a) The hearing officer receives
a written statement from the appealing party requesting the withdrawal;
or
(b) The appealing party makes a
statement on the record at the hearing withdrawing the request for an
administrative hearing.
(4) Upon the agreement of all parties, an
administrative hearing may be conducted tele-phonically or by other electronic
means.
(5) A hearing officer shall
preside over an administrative hearing and shall conduct the administrative
hearing in accordance with:
(a)
KRS 13B.080;
and
(b)
KRS
13B.090.
(6) The issue considered at the hearing shall
be limited to the administrative record on appeal, as required by Section 1(4)
of this administrative regulation.
(7) The hearing officer's decision shall be
issued within sixty (60) calendar days after the close of the official record
of the administrative hearing and shall include:
(a) The findings of facts, conclusions of
law, and the final order solely based on the evidence on the record;
(b) The party that shall pay an
administrative hearing fee in accordance with Section 3 of this administrative
regulation; and
(c) Notice that
judicial review on a final order is available to the parties in accordance with
Section 4 of this administrative regulation.
(8) In accordance with
KRS
205.646(4), a hearing
officer's decision shall constitute the final order in the matter for purposes
of appeal.
Section 3.
Administrative Hearing Fee. The party that receives an adverse final order
shall pay a fee of $600 to the department within thirty (30) calendar days of
the issuance of the final order.
Section
4. Judicial Review of the Final Order.
(1) Judicial review of the hearing officer's
final order is available pursuant to
KRS
13B.140 and
KRS
13B.150.
(2) Within twenty (20) days after the service
of the petition for judicial review under subsection (1) of this section, the
administrative hearings branch shall transmit a certified copy of the official
record of the proceeding under review.
STATUTORY AUTHORITY:
KRS
194A.010(1),
194A.025(3),
194A.030(2),
194A.050(1),
205.520(3),
205.646,
42 C.F.R. Part 438