KMAP BULLETIN: MCO Provider Appeal Process

Date: 03/05/18

MCO GENERAL BULLETIN 18040

Effective with payment denials processed on and after May 1, 2017, the three KanCare managed care organizations (MCOs) standardized the process for disputing a denial of payment by an MCO through submission of a Reconsideration, Appeal, or both to the MCO.

Submission of a Reconsideration is optional, but providers must complete the MCO’s Appeal process prior to requesting a State Fair Hearing. The Reconsideration process offers providers an opportunity to submit a request to the MCOs to review a denial of payment prior to requesting an Appeal. Reference MCO Bulletin 17105. Providers must submit the Appeal within 60 calendar days of the date on the remittance advice (RA), explanation of payment (EOP), or denial notice.

Providers who choose to first submit a Reconsideration to the MCO, rather than an Appeal, must submit the Reconsideration no later than 120 calendar days from the date of the RA, EOP, or denial notice. Providers may terminate the Reconsideration process and submit an Appeal within 60 calendar days of the date of the RA, EOP, or denial notice. Providers who choose to terminate the Reconsideration process, but do not submit an Appeal within 60 calendar days, must wait to receive the Reconsideration resolution notice from the MCO before submitting an Appeal. The MCOs are not required to resolve the Reconsideration within a defined period of time. An additional three calendar days from the RA, EOP, or denial notice sent date are added to the submission timeframe. Once an MCO receives the Appeal, it will review the payment denial and issue an Appeal resolution notice. The MCOs are required to resolve 98% of Appeals within 30 calendar days of receipt and 100% within 60 calendar days of receipt.

A summary of the revised Provider Payment Dispute Resolution Process is available under the Helpful Information heading on the Provider page of Kansas Medical Assistance Program website.