{"data":{"id":"us-ky/krs-205.534","jurisdiction":"us-ky","citation":"KRS 205.534","heading":"Toll -free telephone line -- Duties relating to adverse determinations -- In-","body":"person meeting -- Reprocessing claims -- Internal appeals -- Provider audits --\nTimely decisions on authorization and preauthorization requests -- Monthly\nand annual reports -- Penalties -- Administrative regulations.\n(1) A Medicaid managed care organization with whom the department contracts for the\ndelivery of Medicaid services shall:\n(a) Provide:\n1. A toll-free telephone line for providers to contact the insurer for c laims\nresolution for forty (40) hours a week during normal business hours in\nthis state;\n2. A toll -free telephone line for providers to submit requests for\nauthorizations of covered services during normal business hours and\nextended hours in this state on Monday and Friday through 6 p.m.,\nincluding federal holidays;\n3. With regard to any adverse payment or coverage determination, copies\nof all documents, records, and other information relevant to a\ndetermination, including medical necessity criteria and any  processes,\nstrategies, or evidentiary standards relied upon, if requested by the\nprovider. Documents, records, and other information required to be\nprovided under this paragraph shall be provided at no cost to the\nprovider; and\n4. For any adverse payment or coverage determination, a written reply in\nsufficient detail to inform the provider of all reasons for the\ndetermination. The written reply shall include information about the\nprovider's right to request and receive at no cost to the provider\ndocuments, records, and other information under subparagraph 3. of this\nparagraph;\n(b) Afford each participating provider the opportunity for an in -person meeting\nwith a representative of the managed care organization on:\n1. Any clean claim that remains unpaid in vi olation of KRS 304.17A -700\nto 304.17A-730; and\n2. Any claim that remains unpaid for forty -five (45) days or more after the\ndate the claim is received by the managed care organization and that\nindividually or in the aggregate exceeds two thousand five hundred\ndollars ($2,500);\n(c) Reprocess claims that are  incorrectly paid or denied in error, in compliance\nwith KRS 304.17A-708. The reprocessing shall not require a provider to rebill\nor resubmit claims to obtain correct payment. A claim shall not be denied for\ntimely filing if the initial claim was timely submitted;\n(d) Establish processes for internal appeals, including provisions for:\n1. Allowing a provider to file any grievance or appeal related to the\nreduction or denial of the claim within one hundred twenty (120) days of\nconfirmed receipt of a notificat ion from the managed care organization\nthat payment for a submitted claim has been reduced or denied;\n2. a. Ensuring the timely consideration and disposition of any grievance\nor any appeal within thirty (30) days from the date the grievance or\nappeal is fi led with the managed care organization by a provider\nunder this paragraph.\nb. Failure of the managed care organization to comply with\nsubdivision a. of this subparagraph shall result in a fine or penalty\nas provided in subsection (6) of this section; and\n3. Ensuring that, following the resolution of an appeal that results in a\ndetermination that a monetary amount is owed to a provider, payment is\nmade in full to the provider within thirty (30) days from the date on\nwhich the appeal was resolved; and\n(e) With regard to provider audits:\n1. Allow at least thirty (30) calendar days for a provider to provide or grant\naccess to the requested records;\n2. Complete an audit within one hundred eighty (180) calendar days from\nthe date on which the audit was initiated b y the managed care\norganization unless the provider subject to the audit fails to provide or\ngrant access to requested records in a timely manner;\n3. Only recoup denied payments or issue a demand for payment from a\nprovider upon the final disposition of th e audit, including the appeals\nprocess established in KRS 205.646; and\n4. Base recoupment of claims on the actual overpayment or underpayment\nof claims unless the provider agrees to a settlement to the contrary.\n(2) (a) As used in this subsection:\n1. \"Timely\" means that an authorization or preauthorization request shall\nbe approved:\na. For an expedited authorization request, within twenty -four (24)\nhours after receipt of the request. The timeframe for an expedited\nauthorization request may be extended by up  to fourteen (14) days\nif:\ni. The enrollee requests an extension; or\nii. The Medicaid managed care organization justifies to the\ndepartment a need for additional information and how the\nextension is in the enrollee's interest; and\nb. For a standard authorization request, within five (5) calendar days.\nThe timeframe for a standard authorization request may be\nextended by up to fourteen (14) additional days if:\ni. The provider or enrollee requests an extension; or\nii. The Medicaid managed care organization justifies to the\ndepartment a need for additional information and how the\nextension is in the enrollee's interest; and\n2. a. \"Expedited authorization request\" means a request for\nauthorization or preauthorization where the provider determines\nthat followin g the standard timeframe could seriously jeopardize\nan enrollee's life or health, or ability to attain, maintain, or regain\nmaximum function.\nb. A request for authorization or preauthorization for treatment of an\nenrollee with a diagnosis of substance use disorder shall be\nconsidered an expedited authorization request by the provider and\nthe managed care organization.\n(b) A decision by a managed care organization on an authorization or\npreauthorization request for physical, behavioral, or other medically necessary\nservices shall be made in a timely and consistent manner so that Medicaid\nmembers with comparable medical needs receive a comparable, consistent\nlevel, amount, and duration of services as supported by the member's medical\ncondition, records, and previous affirmative coverage decisions.\n(3) (a) Each managed care organization shall report on a monthly basis to the\ndepartment:\n1. The number and dollar value of claims received that were denied,\nsuspended, or approved for payment;\n2. The number of requests for authorization of services and the number of\nsuch requests that were approved and denied;\n3. The number of internal appeals and grievances filed by members and by\nproviders and the type of service related to the grievance or appeal, the\ntotal dollar amount of all denials being appealed, the time of resolution,\nthe number of internal appeals and grievances where the initial denia l\nwas overturned and the type of service and dollar amount associated\nwith the overturned denials;\n4. For each internal appeal or grievance not resolved within sixty (60)\ncalendar days, the name of the provider who filed the unresolved\ninternal appeal or g rievance, the dollar amount of the claim that was\ndenied if a denial is being appealed, the reason for the delay in resolving\nthe internal appeal or grievance, the current status of the internal appeal\nor grievance, and the outcome determination if rendere d prior to the\nfiling of the report; and\n5. Any other information required by the department.\n(b) The data required in paragraph (a) of this subsection shall be separately\nreported by provider category, as prescribed by the department, and shall at a\nminimum include inpatient acute care hospital services, inpatient psychiatric\nhospital services, outpatient hospital services, residential behavioral health\nservices, and outpatient behavioral health services.\n(4) On a monthly basis, the department shall transm it to the Department of Insurance a\nreport of each corrective action plan, fine, or sanction assessed against a Medicaid\nmanaged care organization for violation of a Medicaid managed care organization's\ncontract relating to prompt payment of claims. The De partment of Insurance shall\nthen make a determination of whether the contract violation was also a violation of\nKRS 304.17A-700 to 304.17A-730.\n(5) By December 15 of each year, the department shall submit to the Legislative\nResearch Commission for referral  to the Interim Joint Committee on Health\nServices, the Legislative Oversight and Investigations Committee, and the Medicaid\nOversight and Advisory Board a report containing the following information for the\nprevious state fiscal year and reported separate ly for each managed care\norganization with whom the department has contracted for the delivery of Medicaid\nservices:\n(a) The number and dollar value of all claims that were received by the managed\ncare organization and the number and dollar value of those claims that were\napproved for payment, denied, or suspended;\n(b) The number of requests for authorization of services received and the number\nof those requests that were approved or denied;\n(c) The number of internal appeals and grievances filed by Medicai d enrollees\nand by providers, the types of services to which the internal appeals and\ngrievances relate, the total dollar amount of denials that were appealed, the\naverage length of time to resolution, the number of internal appeals and\ngrievances where th e initial denial was overturned, and the types of services\nand dollar amount of overturned denials; and\n(d) The number of internal appeals and grievances not resolved within sixty (60)\ncalendar days, the ten (10) most common reasons given for delays, the t otal\ndollar amount when a denial is being appealed, and the number of final\ndeterminations made in favor of a provider.\n(6) Any Medicaid managed care organization that fails to comply with subsection\n(1)(d)2. of this section or KRS 205.522, 205.532 to 205. 536, or 304.17A -515 may\nbe subject to fines, penalties, and sanctions, up to and including termination, as\nestablished under its Medicaid managed care contract with the department.\n(7) The department may promulgate administrative regulations in accordance with\nKRS Chapter 13A to implement and enforce this section.","path":["KRS Chapter 205"],"source_url":"https://apps.legislature.ky.gov/law/statutes/statute.aspx?id=57033","current_through":"Includes enactments through the 2026 Regular Session","vintage":"09/05/2026","retrieved_at":"2026-09-05T20:52:03Z","sha256":"7b9393e6dd607ef2ab9936142bb0c496716b0b41965d5409ca46c64a07843811","source_id":"us-ky","stale":false,"prev":"us-ky/krs-205.533","next":"us-ky/krs-205.535"},"notice":"GroundRules: Original legal text. Not legal advice."}