Bill Text: IA SF2340 | 2017-2018 | 87th General Assembly | Introduced

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Bill Title: A bill for an act relating to Medicaid managed care resolution of payment and notice of change. (Formerly SF 2221.)

Sponsorship: Committee Bill

Status: (Introduced - Dead) 2018-03-15 - Referred to Human Resources. S.J. 693. [SF2340 Detail]

Download: Iowa-2017-SF2340-Introduced.html

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Senate File 2340 - Introduced




                                 SENATE FILE       
                                 BY  COMMITTEE ON HUMAN
                                     RESOURCES

                                 (SUCCESSOR TO SF 2221)

                                      A BILL FOR

  1 An Act relating to Medicaid managed care resolution of payment
  2    and notice of change.
  3 BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF IOWA:
    TLSB 5779SV (2) 87
    pf/rh

PAG LIN



  1  1    Section 1.  MEDICAID MANAGED CARE == RESOLUTION OF PAYMENT
  1  2 AND NOTICE OF CHANGE.  The department of human services
  1  3 shall adopt rules pursuant to chapter 17A and shall amend
  1  4 all Medicaid managed care contracts, to require all of the
  1  5 following:
  1  6    1.  For Medicaid provider claims ultimately found to be
  1  7 incorrectly denied or underpaid through an appeals process or
  1  8 audit, a managed care organization shall pay, in addition to
  1  9 the amount determined to be owed, interest in an amount equal
  1 10 to eighteen percent per annum on the total amount of the claim
  1 11 ultimately authorized as calculated from fifteen days after the
  1 12 date the claim was submitted.
  1 13    2.  A managed care organization shall provide written notice
  1 14 to all affected individuals at least sixty days prior to a
  1 15 change in administrative processes or procedures relating to
  1 16 the scope or coverage of benefits, billings and collections
  1 17 provisions, provider network provisions, member or provider
  1 18 services, prior authorization requirements, or any other terms
  1 19 of a managed care contract or agreement upon which an affected
  1 20 individual relies under Medicaid managed care. A managed care
  1 21 organization may comply with the requirement of providing
  1 22 written notice under this subsection by posting such written
  1 23 notice on the managed care organization's internet site.
  1 24    3.  A managed care organization shall pay, contest, deny, or
  1 25 settle a claim, in whole or in part, within forty=five business
  1 26 days after receipt of the claim.  If a claim is contested
  1 27 or denied, the managed care organization shall, with as much
  1 28 specificity as possible, identify the claim or portion of the
  1 29 claim affected, provide an explanation and the reasons for
  1 30 contesting or denying the claim, and provide the claimant with
  1 31 instructions for appealing the contested or denied claim.
  1 32    4.  A managed care organization shall complete the internal
  1 33 review process for any claim submitted within ninety business
  1 34 days of receipt of the request for internal review.  If the
  1 35 first level of review is not completed within the ninety=day
  2  1 period, the claim shall be subject to contested case review
  2  2 pursuant to chapter 17A, notwithstanding the fact that the
  2  3 claimant has not exhausted the managed care organization's
  2  4 internal review process and received a final written
  2  5 determination from the managed care organization.
  2  6                           EXPLANATION
  2  7 The inclusion of this explanation does not constitute agreement with
  2  8 the explanation's substance by the members of the general assembly.
  2  9    This bill requires the department of human services (DHS)
  2 10 to  adopt administrative rules and amend all Medicaid managed
  2 11 care contracts to provide for compliance with certain notice
  2 12 and payment requirements.
  2 13    The bill requires an MCO to provide written notice to all
  2 14 affected individuals at least 60 days prior to a change in any
  2 15 term of a managed care contract or agreement upon which an
  2 16 affected individual has relied under the Medicaid managed care
  2 17 program.  An MCO may comply with the notice requirements by
  2 18 posting the written notice on the MCO's internet site.
  2 19    The bill requires an MCO to pay, contest, or deny a claim,
  2 20 in whole or in part, within 45 business days after receipt of
  2 21 the claim.  If a claim is contested or denied, the managed
  2 22 care organization shall, with as much specificity as possible,
  2 23 identify the claim or portion of the claim affected, provide
  2 24 an explanation and the reasons for contesting or denying the
  2 25 claim, and provide the claimant with instruction for appeal of
  2 26 the claim.
  2 27    The bill requires an MCO to complete the internal review
  2 28 process for any claim submitted within 90 business days of
  2 29 receipt of the request for internal review.  If the internal
  2 30 review is not completed within the 90=day period, the claim is
  2 31 subject to contested case review pursuant to Code chapter 17A,
  2 32 notwithstanding the fact that the claimant has not exhausted
  2 33 the managed care organization's internal review process and
  2 34 received a final written determination from the MCO.
       LSB 5779SV (2) 87
       pf/rh