{"data":{"id":"us-ky/krs-205.646","jurisdiction":"us-ky","citation":"KRS 205.646","heading":"External independent third -party review of Medicaid managed care","body":"organization's final decision denying a health care service or a claim for\nreimbursement -- Submission of multiple claims in a single review -- Appeal --\nAdministrative regulations -- Applicability of statute.\n(1) As used in this section:\n(a) \"Administrative appeals hearing\" means a formal adjudicatory proceeding\nconducted by the Office of Administrative Hearings within the Department of\nLaw in accordance with KRS Chapter 13B;\n(b) \"Department\" means the Department for Medicaid Services;\n(c) \"External independent third -party review\" means a review performed by an\nindependent third party outside of the Medicaid managed care organization's\ninternal appeal process pursuant to admi nistrative regulations promulgated by\nthe department;\n(d) \"Medicaid managed care organization\" means an entity for which the\nDepartment for Medicaid Services has contracted to serve as a managed care\norganization as defined in 42 C.F.R. sec. 438.2; and\n(e) \"Provider\" means any person or entity licensed in Kentucky as defined in\nKRS 304.17A-700(9) that provides covered services to enrollees.\n(2) Notwithstanding any law to the contrary, a provider who has exhausted the written\ninternal appeals process of a Me dicaid managed care organization shall be entitled\nto an external independent third -party review of the Medicaid managed care\norganization's final decision that denies, in whole or in part, a health care service to\nan enrollee or a claim for reimbursement to a provider for a health care service\nrendered by the provider to an enrollee of the Medicaid managed care organization.\nA provider may submit multiple claims to be appealed in a single external\nindependent third-party review if the provider alleges that a Medicaid managed care\norganization has implemented a policy or practice that results in the denial, in\nwhole or in part, of those claims.\n(3) A Medicaid managed care organization's letter to a provider reflecting the final\ndecision of the provider's internal appeal shall include:\n(a) A statement that the provider's internal appeal rights within the Medicaid\nmanaged care organization have been exhausted;\n(b) A statement that the provider is entitled to an external independent third -party\nreview; and\n(c) The time period and address to request an external independent third -party\nreview.\n(4) A Medicaid managed care organization or provider shall be entitled to appeal a\nfinal decision of the external independent third -party review to the Office of\nAdministrative Hearings within the Department of Law for an administrative\nhearing to be held in accordance with KRS Chapter 13B. An appeal shall be filed\nwithin thirty (30) days from the appealing party's receipt of the final decision of the\nexternal independent third-party review. A decision of the Office of Administrative\nHearings within the Department of Law shall be final for purposes of judicial\nappeal. Any appeal of a final decision of an external independent third -party review\ninvolving the submission of m ultiple claims as allowed under subsection (2) of this\nsection shall be conducted as a single administrative hearing under this subsection.\n(5) The department shall promulgate administrative regulations to implement the\nexternal independent third-party review as required by this section.\n(6) The department shall promulgate administrative regulations to establish reasonable\nfees, not to exceed one thousand dollars ($1,000), to defray expenses associated\nwith an administrative hearing that shall be paid by th e party who does not prevail\nin the administrative hearing. If the administrative hearing is an appeal of a final\ndecision of an external independent third -party review involving the submission of\nmultiple claims as allowed under subsection (2) of this sec tion, only one (1) fee\nshall be assessed under this subsection against the party who does not prevail.\n(7) This section shall apply to all contracts or master agreements between Medicaid\nmanaged care organizations and the Commonwealth of Kentucky entered i nto or\nrenewed on or after July 1, 2016.","path":["KRS Chapter 205"],"source_url":"https://apps.legislature.ky.gov/law/statutes/statute.aspx?id=56581","current_through":"Includes enactments through the 2026 Regular Session","vintage":"09/05/2026","retrieved_at":"2026-09-05T20:52:04Z","sha256":"5665b72c4f76898bbff199e68b911e09503f107201fdce9c43446f8abaf58088","source_id":"us-ky","stale":false,"prev":"us-ky/krs-205.645","next":"us-ky/krs-205.647"},"notice":"GroundRules: Original legal text. Not legal advice."}