Effective with payment denials processed on and after May 1, 2017, the three KanCare managed care organizations (MCOs) standardized the Provider Appeal process for all KanCare providers. Providers continue to have the opportunity to dispute a denial of payment, in whole or in part, from an MCO by submitting a Reconsideration request or an Appeal request or both to the MCO.
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 who choose to first submit a Reconsideration request to the MCO, rather than an Appeal request, must submit the Reconsideration request no later than 120 calendar days from the date of the remittance advice (RA), explanation of payment (EOP), or denial notice.
Providers may terminate the Reconsideration process and submit an Appeal request 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 request within 60 calendar days, must wait to receive the Reconsideration resolution notice from the MCO before submitting an Appeal request. Three calendar days are added to the submission timeframes if the RA, EOP, or denial notice is mailed. The MCOs are not required to resolve the Reconsideration request within a defined period of time.
Providers may submit an Appeal request to the MCO instead of submitting a Reconsideration request or after receipt of the Reconsideration resolution notice. Providers who choose not to submit a Reconsideration request must submit an Appeal request within 60 calendar days of the date on the RA, EOP, or denial notice. The Reconsideration process is optional, but providers must complete the MCO’s Appeal process prior to requesting a State Fair Hearing. The MCOs are required to resolve 98% of Appeal requests 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 (KMAP) website.
