HB 1275

Bill Subjects

Abstract

Allows a provider that has entered into a contract with a managed care organization, after exhausting any internal procedures of the managed care organization for provider grievances and appeals, to request an administrative appeal within the office of Medicaid policy and planning of the managed care organization's action in denying or reducing reimbursement for claims for covered services provided to an applicant, pending applicant, conditionally eligible individual, or member. Establishes a procedure for an administrative appeal, including a hearing before an administrative law judge that could be followed by agency review and then by judicial review. Prohibits a provision in a contract between a provider and a managed care organization that would negate or restrict the right of a provider to an administrative appeal and provides that such a contract provision is void and unenforceable. Repeals a provision under which Medicaid law is controlling when Medicaid law conflicts with insurance law. Provides that if the office of the secretary of family and social services or a contractor of the office fails to pay or denies a clean claim for any eligible Medicaid service within certain time limits due to the office or contractor incorrectly processing the clean claim because of errors attributable to the internal system of an insurer or managed care organization, the office or contractor may not assert that the provider failed to meet the timely filing requirements for the claim. Requires the office of the secretary of family and social services (FSSA) to prepare a report that describes every type of report that must be prepared by a Medicaid contractor or managed care entity and submitted to FSSA or the office of Medicaid policy and planning. Specifies the information that must be contained in the report. Requires FSSA to submit the report to the Medicaid advisory committee (advisory committee) and the general assembly. Requires the advisory committee to hold public hearings on the report.