Bill Text: IA SF211 | 2019-2020 | 88th General Assembly | Introduced

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Bill Title: A bill for an act relating to a Medicaid managed care external review process for Medicaid provider appeals.

Spectrum: Partisan Bill (Democrat 2-0)

Status: (Introduced - Dead) 2019-02-12 - Subcommittee: Segebart, Greene, and Ragan. S.J. 287. [SF211 Detail]

Download: Iowa-2019-SF211-Introduced.html

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Senate File 211 - Introduced
SENATE FILE 211
BY MATHIS and RAGAN
A BILL FOR
An Act relating to a Medicaid managed care external review
process for Medicaid provider appeals.
BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF IOWA:
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Section 1. MEDICAID MANAGED CARE —— EXTERNAL REVIEW OF
PROVIDER APPEALS.
1. a. A Medicaid managed care organization under contract
with the state shall include in any written response to
a Medicaid provider under contract with the managed care
organization that reflects a final adverse determination of the
managed care organization’s internal appeal process relative to
an appeal filed by the Medicaid provider, all of the following:
(1) A statement that the Medicaid provider’s internal
appeal rights within the managed care organization have been
exhausted.
(2) A statement that the Medicaid provider is entitled to
an external independent third-party review pursuant to this
section.
(3) The requirements for requesting an external independent
third-party review.
b. If a managed care organization’s written response does
not comply with the requirements of paragraph “a”, the managed
care organization shall pay to the affected Medicaid provider a
penalty not to exceed one thousand dollars.
2. a. A Medicaid provider who has been denied the provision
of a service to a Medicaid member or a claim for reimbursement
for a service rendered to a Medicaid member, and who has
exhausted the internal appeals process of a managed care
organization, shall be entitled to an external independent
third-party review of the managed care organization’s final
adverse determination.
b. To request an external independent third-party review of
a final adverse determination by a managed care organization,
an aggrieved Medicaid provider shall submit a written request
for such review to the managed care organization within sixty
calendar days of receiving the final adverse determination.
c. A Medicaid provider’s request for such review shall
include all of the following:
(1) Identification of each specific issue and dispute
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directly related to the final adverse determination issued by
the managed care organization.
(2) A statement of the basis upon which the Medicaid
provider believes the managed care organization’s determination
to be erroneous.
(3) The Medicaid provider’s designated contact information,
including name, mailing address, phone number, fax number, and
email address.
3. a. Within five business days of receiving a Medicaid
provider’s request for review pursuant to this subsection, the
managed care organization shall do all of the following:
(1) Confirm to the Medicaid provider’s designated contact,
in writing, that the managed care organization has received the
request for review.
(2) Notify the department of the Medicaid provider’s
request for review.
(3) Notify the affected Medicaid member of the Medicaid
provider’s request for review, if the review is related to the
denial of a service.
b. If the managed care organization fails to satisfy the
requirements of this subsection 3, the Medicaid provider shall
automatically prevail in the review.
4. a. Within fifteen calendar days of receiving a Medicaid
provider’s request for external independent third-party review,
the managed care organization shall do all of the following:
(1) Submit to the department all documentation submitted
by the Medicaid provider in the course of the managed care
organization’s internal appeal process.
(2) Provide the managed care organization’s designated
contact information, including name, mailing address, phone
number, fax number, and email address.
b. If a managed care organization fails to satisfy the
requirements of this subsection 4, the Medicaid provider shall
automatically prevail in the review.
5. An external independent third-party review shall
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automatically extend the deadline to file an appeal for a
contested case hearing under chapter 17A, pending the outcome
of the external independent third-party review, until thirty
calendar days following receipt of the review decision by the
Medicaid provider.
6. Upon receiving notification of a request for external
independent third-party review, the department shall do all of
the following:
a. Assign the review to an external independent third-party
reviewer.
b. Notify the managed care organization of the identity of
the external independent third-party reviewer.
c. Notify the Medicaid provider’s designated contact of the
identity of the external independent third-party reviewer.
7. The department shall deny a request for an external
independent third-party review if the requesting Medicaid
provider fails to exhaust the managed care organization’s
internal appeals process or fails to submit a timely request
for an external independent third-party review pursuant to this
subsection.
8. a. Multiple appeals through the external independent
third-party review process regarding the same Medicaid
member, a common question of fact, or interpretation of common
applicable regulations or reimbursement requirements may
be combined and determined in one action upon request of a
party in accordance with rules and regulations adopted by the
department.
b. The Medicaid provider that initiated a request for
an external independent third-party review, or one or more
other Medicaid providers, may add claims to such an existing
external independent third-party review following exhaustion
of any applicable managed care organization internal appeals
process, if the claims involve a common question of fact
or interpretation of common applicable regulations or
reimbursement requirements.
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9. Documentation reviewed by the external independent
third-party reviewer shall be limited to documentation
submitted pursuant to subsection 4.
10. An external independent third-party reviewer shall do
all of the following:
a. Conduct an external independent third-party review
of any claim submitted to the reviewer pursuant to this
subsection.
b. Within thirty calendar days from receiving the request
for review from the department and the documentation submitted
pursuant to subsection 4, issue the reviewer’s final decision
to the Medicaid provider’s designated contact, the managed
care organization’s designated contact, the department, and
the affected Medicaid member if the decision involves a denial
of service. The reviewer may extend the time to issue a final
decision by fourteen calendar days upon agreement of all
parties to the review.
11. The department shall enter into a contract with
an independent review organization that does not have a
conflict of interest with the department or any managed care
organization to conduct the independent third-party reviews
under this section.
a. A party, including the affected Medicaid member or
Medicaid provider, may appeal a final decision of the external
independent third-party reviewer in a contested case proceeding
in accordance with chapter 17A within thirty calendar days from
receiving the final decision. A final decision in a contested
case proceeding is subject to judicial review.
b. The final decision of any external independent
third-party review conducted pursuant to this subsection shall
also direct the nonprevailing party to pay an amount equal to
the costs of the review to the external independent third-party
reviewer. Any payment ordered pursuant to this subsection
shall be stayed pending any appeal of the review. If the
final outcome of any appeal is to reverse the decision of the
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external independent third-party review, the nonprevailing
party shall pay the costs of the review to the external
independent third-party reviewer within forty-five calendar
days of entry of the final order.
EXPLANATION
The inclusion of this explanation does not constitute agreement with
the explanation’s substance by the members of the general assembly.
This bill establishes an external review process
for Medicaid providers for the review of final adverse
determinations of a Medicaid managed care organization’s
(MCO’s) internal appeal processes. The external review
process would be available to a Medicaid provider who has been
denied the provision of services to a Medicaid member or a
claim for reimbursement, and who has exhausted the internal
appeals process of an MCO. The bill specifies the process
for the external review and provides that a final decision
of an external reviewer may be reviewed in a contested case
proceeding pursuant to Code chapter 17A, and is ultimately
subject to judicial review.
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