Bill Text: IA SF2221 | 2017-2018 | 87th General Assembly | Introduced
Bill Title: A bill for an act relating to Medicaid managed care policies and procedures. (See SF 2340.)
Spectrum: Partisan Bill (Republican 1-0)
Status: (Introduced - Dead) 2018-02-14 - Subcommittee recommends amendment and passage. [SF2221 Detail]
Download: Iowa-2017-SF2221-Introduced.html
Senate File 2221 - Introduced SENATE FILE BY CHELGREN A BILL FOR 1 An Act relating to Medicaid managed care policies and 2 procedures. 3 BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF IOWA: TLSB 5779XS (4) 87 pf/rh PAG LIN 1 1 Section 1. MEDICAID MANAGED CARE == POLICIES AND 1 2 PROCEDURES. The department of human services shall adopt rules 1 3 pursuant to chapter 17A and shall amend all Medicaid managed 1 4 care contracts, to require all of the following: 1 5 1. If a managed care organization fails to pay, contest, 1 6 deny, or settle a clean claim in full within the time frame 1 7 established by the managed care contract, the managed care 1 8 organization shall pay the claimant interest in an amount equal 1 9 to eighteen percent per annum on the total amount of the claim 1 10 ultimately authorized, as calculated from fifteen days after 1 11 the date the claim was submitted. 1 12 2. For Medicaid provider claims ultimately found to be 1 13 incorrectly denied or underpaid through an appeals process or 1 14 audit, a managed care organization shall pay, in addition to 1 15 the amount determined to be owed, interest in an amount equal 1 16 to eighteen percent per annum on the total amount of the claim 1 17 ultimately authorized as calculated from fifteen days after the 1 18 date the claim was submitted. 1 19 3. A managed care organization shall provide written notice 1 20 to all affected individuals at least thirty days prior to a 1 21 change in administrative processes or procedures relating to 1 22 the scope or coverage of benefits, billings and collections 1 23 provisions, provider network provisions, member or provider 1 24 services, prior authorization requirements, or any other terms 1 25 of a managed care contract or agreement upon which an affected 1 26 individual relies under Medicaid managed care. 1 27 4. A managed care organization shall pay, contest, deny, or 1 28 settle a claim, in whole or in part, within forty=five business 1 29 days after receipt of the claim. If a claim is contested 1 30 or denied, the managed care organization shall, with as much 1 31 specificity as possible, identify the claim or portion of the 1 32 claim affected, provide an explanation and the reasons for 1 33 contesting or denying the claim, and provide the claimant with 1 34 instructions for appealing the contested or denied claim. 1 35 5. A managed care organization shall complete the internal 2 1 review process for any claim submitted within ninety business 2 2 days of receipt of the request for internal review. If the 2 3 first level of review is not completed within the ninety=day 2 4 period, the claim shall be subject to contested case review 2 5 pursuant to chapter 17A, notwithstanding the fact that the 2 6 claimant has not exhausted the managed care organization's 2 7 internal review process and received a final written 2 8 determination from the managed care organization. 2 9 EXPLANATION 2 10 The inclusion of this explanation does not constitute agreement with 2 11 the explanation's substance by the members of the general assembly. 2 12 This bill requires the department of human services (DHS) 2 13 to adopt administrative rules and amend all Medicaid managed 2 14 care contracts to require compliance with various policies and 2 15 procedures. 2 16 The bill provides that if a managed care organization (MCO) 2 17 fails to pay, contest, deny, or settle a clean claim in full 2 18 within the time frame established by the managed care contract, 2 19 the MCO is required to pay the claimant interest equal to 18 2 20 percent per annum on the total amount of the claim ultimately 2 21 authorized as calculated from 15 days after the date the claim 2 22 was submitted. For claims ultimately found to be incorrectly 2 23 denied or underpaid through an appeals process or audit, an MCO 2 24 is required to pay, in addition to the amount determined to be 2 25 owed, interest of 18 percent per annum on the total amount of 2 26 the claim authorized. 2 27 The bill requires an MCO to provide written notice to all 2 28 affected individuals at least 30 days prior to a change in any 2 29 term of a managed care contract or agreement upon which an 2 30 affected individual has relied under the Medicaid managed care 2 31 program. 2 32 The bill requires an MCO to pay, contest, or deny a claim, 2 33 in whole or in part, within 45 business days after receipt of 2 34 the claim. If a claim is contested or denied, the managed 2 35 care organization shall, with as much specificity as possible, 3 1 identify the claim or portion of the claim affected, provide 3 2 an explanation and the reasons for contesting or denying the 3 3 claim, and provide the claimant with instruction for appeal of 3 4 the claim. 3 5 The bill requires an MCO to complete the internal review 3 6 process for any claim submitted within 90 business days of 3 7 receipt of the request for internal review. If the internal 3 8 review is not completed within the 90=day period, the claim is 3 9 subject to contested case review pursuant to Code chapter 17A, 3 10 notwithstanding the fact that the claimant has not exhausted 3 11 the managed care organization's internal review process and 3 12 received a final written determination from the MCO. LSB 5779XS (4) 87 pf/rh
