SUBPART D. MEDICAID MANAGED CARE

INDEPENDENT CLAIMS REVIEW PROCESS

§460.81. Right of providers to independent review; applicability

            A. If a provider's claim is subject to an adverse determination evidenced in a remittance advice or other written or electronic notice from a managed care organization, then the provider shall have a right to an independent review of the adverse action taken by the managed care organization. Such independent review shall be governed by the provisions of this Subpart and any applicable rules and regulations promulgated by the department pursuant to the Administrative Procedure Act. The provisions of this Subpart shall not otherwise prohibit or limit any alternative legal or contractual remedy available to a provider to contest the partial or total denial of a claim for payment for healthcare services. Any contractual provision executed between a provider and a managed care organization which seeks to limit or otherwise impede the appeal process as set forth in this Subpart shall be null, void, and deemed to be contrary to the public policy of this state.

            B. The provisions of this Subpart shall not apply to any adverse determination associated with a claim filed with a managed care organization prior to January 1, 2018, regardless of whether the claim is re-filed after that date. For all adverse determinations related to claims filed on or after January 1, 2018, the state shall not mandate that the provider and managed care organization resolve the claim payment dispute through arbitration.

            C. An adverse determination involved in litigation or arbitration or not associated with a Medicaid enrollee shall not be eligible for independent review under the provisions of this Subpart.

            D. Notwithstanding any other provision of law, a mental health rehabilitation services provider shall have the right to an independent review of an adverse determination taken by a managed care organization that results in a recoupment of the payment of a claim based upon a finding of waste or abuse.

            Acts 2017, No. 349, §2; Acts 2021, No. 204, §2, eff. Jan. 1, 2022.