Bill Text: IA SF2259 | 2017-2018 | 87th General Assembly | Introduced
Bill Title: A bill for an act relating to Medicaid managed care, including process and contract requirements, and oversight.
Spectrum: Partisan Bill (Democrat 1-0)
Status: (Introduced - Dead) 2018-02-13 - Subcommittee: Chelgren, Mathis, and Segebart. S.J. 307. [SF2259 Detail]
Download: Iowa-2017-SF2259-Introduced.html
Senate File 2259 - Introduced SENATE FILE BY PETERSEN A BILL FOR 1 An Act relating to Medicaid managed care, including process and 2 contract requirements, and oversight. 3 BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF IOWA: TLSB 6049XS (8) 87 pf/rh PAG LIN 1 1 Section 1. MEDICAID MANAGED CARE ==== PROCESS AND CONTRACT 1 2 REQUIREMENTS ==== OVERSIGHT. The department of human services 1 3 shall adopt rules pursuant to chapter 17A and shall amend all 1 4 Medicaid managed care contracts to provide for all of the 1 5 following relative to managed care organizations under contract 1 6 with the state: 1 7 1. Upon request by a Medicaid provider, the department 1 8 shall provide accurate and uniform patient encounter data to 1 9 a Medicaid provider, under contract with the managed care 1 10 organization, within sixty calendar days of the request. The 1 11 provision of the patient encounter data shall comply with the 1 12 federal Health Insurance Portability and Accountability Act 1 13 and any other applicable federal and state laws and regulatory 1 14 requirements and shall include but not be limited to the 1 15 managed care organization's claim number, the Medicaid member 1 16 identification number, the Medicaid member's name, the type of 1 17 claim, the amount billed by revenue code and procedure code, 1 18 the managed care organization's paid amount and payment date, 1 19 and the hospital patient account number, as applicable. The 1 20 department may charge a reasonable fee for the actual cost of 1 21 providing the patient encounter data to a Medicaid provider. 1 22 2. A managed care organization shall provide documentation 1 23 to a Medicaid provider claimant when the managed care 1 24 organization contests or denies a claim, in whole or in part, 1 25 within fifteen calendar days after receipt of the claim. The 1 26 documentation shall, with as much specificity as possible, 1 27 identify the claim or portion of the claim affected, and shall 1 28 provide an explanation including the reasons for contesting 1 29 or denying the claim utilizing the federal Health Insurance 1 30 Portability and Accountability Act standard claim adjustment 1 31 reason codes and remittance advice remark codes, or other 1 32 standard adjustment reasons and remark codes approved by rule 1 33 of the department. A managed care organization shall utilize 1 34 the standard coding and format of responses, established 1 35 uniformly across all managed care organizations, as required 2 1 by rule of the department. A managed care organization shall 2 2 offer quarterly in=person training on claim adjustment reason 2 3 codes and remark codes required by the department and utilized 2 4 by the managed care organization. 2 5 3. A managed care organization shall offer quarterly 2 6 in=person education regarding billing guidelines, reimbursement 2 7 requirements, and program policies and procedures utilizing a 2 8 format approved by the department and incorporating information 2 9 collected through surveys of Medicaid providers. 2 10 4. The department shall develop and require utilization of 2 11 uniform standards by all managed care organizations applicable 2 12 to all of the following: 2 13 a. A standardized enrollment form and a uniform process for 2 14 credentialing and recredentialing Medicaid providers. 2 15 b. Procedures, requirements, and periodic reviews 2 16 and reporting of reductions in and limitations for prior 2 17 authorization relative to services and prescriptions. 2 18 c. Retrospective utilization review of hospital 2 19 readmissions that complies with any applicable federal law 2 20 or regulatory requirements, prohibiting such reviews for a 2 21 Medicaid member who is readmitted with a related medical 2 22 condition as an inpatient to a hospital more than fifteen 2 23 calendar days after the Medicaid member's discharge from the 2 24 hospital. 2 25 d. A requirement that a managed care organization, within 2 26 sixty calendar days of receiving an appeal request, provides 2 27 notice and resolves one hundred percent of provider appeals, 2 28 subject to remedies, including but not limited to liquidated 2 29 damages, if such appeals are not resolved within the required 2 30 time frame. 2 31 5. The department shall enter into a contract with an 2 32 independent auditor for the purpose of reviewing, at least once 2 33 each calendar year, a random sample of all claims paid and 2 34 denied by each managed care organization and each managed care 2 35 organization's subcontractors. Each managed care organization 3 1 and each managed care organization's subcontractors shall 3 2 pay any claim that the independent auditor determines to be 3 3 incorrectly denied, any applicable liquidated damages, and any 3 4 costs attributable to the annual audit. 3 5 6. A managed care organization shall pay one hundred percent 3 6 of the state=established per diem rate to nursing facilities 3 7 for those nursing facility residents enrolled in Medicaid 3 8 during any recredentialing process caused by a change in 3 9 ownership of the nursing facility. 3 10 7. A managed care organization shall not discriminate 3 11 against any licensed pharmacy or pharmacist located within the 3 12 geographic coverage area of the managed care organization that 3 13 is willing to meet the conditions for participating established 3 14 by the department and to accept reasonable contract terms 3 15 offered by the managed care organization. 3 16 Sec. 2. MEDICAID MANAGED CARE ORGANIZATION APPEALS PROCESS 3 17 == EXTERNAL REVIEW. 3 18 1. a. A Medicaid managed care organization under contract 3 19 with the state shall include in any written response to 3 20 a Medicaid provider under contract with the managed care 3 21 organization that reflects a final adverse determination of the 3 22 managed care organization's internal appeal process relative to 3 23 an appeal filed by the Medicaid provider, all of the following: 3 24 (1) A statement that the Medicaid provider's internal 3 25 appeal rights within the managed care organization have been 3 26 exhausted. 3 27 (2) A statement that the Medicaid provider is entitled to 3 28 an external independent third=party review pursuant to this 3 29 section. 3 30 (3) The requirements for requesting an external independent 3 31 third=party review. 3 32 b. If a managed care organization's written response does 3 33 not comply with the requirements of paragraph "a", the managed 3 34 care organization shall pay to the affected Medicaid provider a 3 35 penalty not to exceed one thousand dollars. 4 1 2. a. A Medicaid provider who has been denied the provision 4 2 of a service to a Medicaid member or a claim for reimbursement 4 3 for a service rendered to a Medicaid member, and who has 4 4 exhausted the internal appeals process of a managed care 4 5 organization, shall be entitled to an external independent 4 6 third=party review of the managed care organization's final 4 7 adverse determination. 4 8 b. To request an external independent third=party review of 4 9 a final adverse determination by a managed care organization, 4 10 an aggrieved Medicaid provider shall submit a written request 4 11 for such review to the managed care organization within sixty 4 12 calendar days of receiving the final adverse determination. 4 13 c. A Medicaid provider's request for such review shall 4 14 include all of the following: 4 15 (1) Identification of each specific issue and dispute 4 16 directly related to the final adverse determination issued by 4 17 the managed care organization. 4 18 (2) A statement of the basis upon which the Medicaid 4 19 provider believes the managed care organization's determination 4 20 to be erroneous. 4 21 (3) The Medicaid provider's designated contact information, 4 22 including name, mailing address, phone number, fax number, and 4 23 email address. 4 24 3. a. Within five business days of receiving a Medicaid 4 25 provider's request for review pursuant to this subsection, the 4 26 managed care organization shall do all of the following: 4 27 (1) Confirm to the Medicaid provider's designated contact, 4 28 in writing, that the managed care organization has received the 4 29 request for review. 4 30 (2) Notify the department of the Medicaid provider's 4 31 request for review. 4 32 (3) Notify the affected Medicaid member of the Medicaid 4 33 provider's request for review, if the review is related to the 4 34 denial of a service. 4 35 b. If the managed care organization fails to satisfy the 5 1 requirements of this subsection 3, the Medicaid provider shall 5 2 automatically prevail in the review. 5 3 4. a. Within fifteen calendar days of receiving a Medicaid 5 4 provider's request for external independent third=party review, 5 5 the managed care organization shall do all of the following: 5 6 (1) Submit to the department all documentation submitted 5 7 by the Medicaid provider in the course of the managed care 5 8 organization's internal appeal process. 5 9 (2) Provide the managed care organization's designated 5 10 contact information, including name, mailing address, phone 5 11 number, fax number, and email address. 5 12 b. If a managed care organization fails to satisfy the 5 13 requirements of this subsection 4, the Medicaid provider shall 5 14 automatically prevail in the review. 5 15 5. An external independent third=party review shall 5 16 automatically extend the deadline to file an appeal for a 5 17 contested case hearing under chapter 17A, pending the outcome 5 18 of the external independent third=party review, until thirty 5 19 calendar days following receipt of the review decision by the 5 20 Medicaid provider. 5 21 6. Upon receiving notification of a request for external 5 22 independent third=party review, the department shall do all of 5 23 the following: 5 24 a. Assign the review to an external independent third=party 5 25 reviewer. 5 26 b. Notify the managed care organization of the identity of 5 27 the external independent third=party reviewer. 5 28 c. Notify the Medicaid provider's designated contact of the 5 29 identity of the external independent third=party reviewer. 5 30 7. The department shall deny a request for an external 5 31 independent third=party review if the requesting Medicaid 5 32 provider fails to exhaust the managed care organization's 5 33 internal appeals process or fails to submit a timely request 5 34 for an external independent third=party review pursuant to this 5 35 subsection. 6 1 8. a. Multiple appeals through the external independent 6 2 third=party review process regarding the same Medicaid 6 3 member, a common question of fact, or interpretation of common 6 4 applicable regulations or reimbursement requirements may 6 5 be combined and determined in one action upon request of a 6 6 party in accordance with rules and regulations adopted by the 6 7 department. 6 8 b. The Medicaid provider that initiated a request for 6 9 an external independent third=party review, or one or more 6 10 other Medicaid providers, may add claims to such an existing 6 11 external independent third=party review following exhaustion 6 12 of any applicable managed care organization internal appeals 6 13 process, if the claims involve a common question of fact 6 14 or interpretation of common applicable regulations or 6 15 reimbursement requirements. 6 16 9. Documentation reviewed by the external independent 6 17 third=party reviewer shall be limited to documentation 6 18 submitted pursuant to subsection 4. 6 19 10. An external independent third=party reviewer shall do 6 20 all of the following: 6 21 a. Conduct an external independent third=party review 6 22 of any claim submitted to the reviewer pursuant to this 6 23 subsection. 6 24 b. Within thirty calendar days from receiving the request 6 25 for review from the department and the documentation submitted 6 26 pursuant to subsection 4, issue the reviewer's final decision 6 27 to the Medicaid provider's designated contact, the managed 6 28 care organization's designated contact, the department, and 6 29 the affected Medicaid member if the decision involves a denial 6 30 of service. The reviewer may extend the time to issue a final 6 31 decision by fourteen calendar days upon agreement of all 6 32 parties to the review. 6 33 11. The department shall enter into a contract with 6 34 an independent review organization that does not have a 6 35 conflict of interest with the department or any managed care 7 1 organization to conduct the independent third=party reviews 7 2 under this section. 7 3 a. A party, including the affected Medicaid member or 7 4 Medicaid provider, may appeal a final decision of the external 7 5 independent third=party reviewer in a contested case proceeding 7 6 in accordance with chapter 17A within thirty calendar days from 7 7 receiving the final decision. A final decision in a contested 7 8 case proceeding is subject to judicial review. 7 9 b. The final decision of any external independent 7 10 third=party review conducted pursuant to this subsection shall 7 11 also direct the nonprevailing party to pay an amount equal to 7 12 the costs of the review to the external independent third=party 7 13 reviewer. Any payment ordered pursuant to this subsection 7 14 shall be stayed pending any appeal of the review. If the 7 15 final outcome of any appeal is to reverse the decision of the 7 16 external independent third=party review, the nonprevailing 7 17 party shall pay the costs of the review to the external 7 18 independent third=party reviewer within forty=five calendar 7 19 days of entry of the final order. 7 20 EXPLANATION 7 21 The inclusion of this explanation does not constitute agreement with 7 22 the explanation's substance by the members of the general assembly. 7 23 This bill relates to Medicaid managed care including process 7 24 and contract requirements, and oversight. 7 25 The bill requires the department of human services (DHS) to 7 26 adopt administrative rules and amend all Medicaid managed care 7 27 contracts to administer the provisions of the bill. 7 28 The bill requires that, upon request by a Medicaid provider, 7 29 DHS shall provide accurate and uniform patient encounter data 7 30 to a Medicaid provider, under contract with a managed care 7 31 organization (MCO), within 60 calendar days of the request. 7 32 DHS may charge a reasonable fee for the actual cost of 7 33 providing the patient encounter data to a Medicaid provider. 7 34 The bill requires an MCO to provide documentation to a 7 35 Medicaid provider claimant when the MCO contests or denies 8 1 a claim, in whole or in part, within 15 calendar days after 8 2 receipt of the claim. The bill specifies the information to be 8 3 included in the documentation, requires the MCO to utilize the 8 4 standard coding and format of responses, established uniformly 8 5 across all MCOs by DHS, and requires MCOs to offer quarterly 8 6 in=person training on claim adjustment reason codes and remark 8 7 codes. 8 8 The bill requires MCOs to offer quarterly in=person 8 9 education regarding billing guidelines, reimbursement 8 10 requirements, and program policies and procedures utilizing a 8 11 format approved by DHS and incorporating information collected 8 12 through surveys of Medicaid providers. 8 13 The bill requires DHS to develop uniform standards and 8 14 require utilization of such uniform standards by all MCOs 8 15 regarding a standardized enrollment form and a uniform process 8 16 for credentialing and recredentialing Medicaid providers; 8 17 procedures, requirements, and periodic reviews and reporting of 8 18 reductions in and limitations for prior authorization relative 8 19 to services and prescriptions; retrospective utilization review 8 20 of hospital readmissions; a grievance, appeal, external review, 8 21 and state fair hearing process; and resolution of all appeals 8 22 within a 60=day time frame. 8 23 The bill requires DHS to enter into a contract with an 8 24 independent auditor to, at least annually, review a random 8 25 sample of all claims paid and denied by each MCO and each MCO's 8 26 subcontractors, and provides for payment by an MCO of any claim 8 27 that the independent auditor determines to be incorrectly 8 28 denied, any applicable liquidated damages, and any costs 8 29 attributable to the annual audit. 8 30 The bill requires an MCO to pay 100 percent of the 8 31 state=established per diem rate to nursing facilities for those 8 32 nursing facility residents enrolled in Medicaid during any 8 33 recredentialing process caused by a change in ownership of the 8 34 nursing facility. 8 35 The bill prohibits MCOs from discriminating against any 9 1 licensed pharmacy or pharmacist located within the geographic 9 2 coverage area of the MCO that is willing to meet the conditions 9 3 for participating established by DHS and to accept reasonable 9 4 contract terms offered by the MCO. 9 5 The bill also establishes an external review process for the 9 6 review of final adverse determinations of the MCOs' internal 9 7 appeal processes. The bill provides that a final decision 9 8 of an external reviewer may be reviewed in a contested case 9 9 proceeding pursuant to Code chapter 17A, and ultimately is 9 10 subject to judicial review. LSB 6049XS (8) 87 pf/rh
