How do I submit a managed care provider grievance?

The provider or their authorized representative may submit a provider grievance either orally or in writing. The contractor cannot require a written form from the provider or their representative for a grievance.

To submit a managed care grievance by telephone call:

• Healthy Blue:  Provider services: 833-838-2995
                         Claims grievance department: 800-282-4548
                         Your local provider relations account management
                          representative1-833-838-2593 (TTY 711)
• Sunflower: 1-877-644-4623 (TTY 711)
• United:1-877-542-9235

To submit a managed care grievance by fax send to:

• Healthy Blue: 1-844-664-7183
• Sunflower:1-888-453-4755
• United: Not Available

To submit a managed care grievance by mail send to:

Healthy Blue
Healthy Blue Kansas
Provider Grievances
P.O. Box 61599
Virginia Beach, VA 23466-1599

Sunflower
Sunflower Health Plan Quality Department
8325 Lenexa Drive
Lenexa, KS 66214

United
United Healthcare Attn: Formal Grievances and Claims Appeals
PO Box 31364
Salt Lake City, UT 84131-0364

To submit a managed care grievance in person go to:

Healthy Blue
Not Available

Sunflower
Sunflower Health Plan Quality Department
8325 Lenexa Drive
Lenexa, KS 66214

United
United Healthcare
10895 Grandview Drive, Suite 200
Overland Park, KS 66210

Is there a managed care grievance form?

No specific grievance form is required when submitting a provider grievance.

Is there a deadline for filing a managed care provider grievance?

Yes, a provider or their authorized representative must submit a provider grievance within 180 calendar days of the date of the incident being grieved.

What is the process once a managed care provider grievance has been submitted?

The MCO shall sent the letter of grievances acknowledgement to the beneficiary, member or their authorized representative within 10 calendar days from the date of receipt.

98% of all grievances must be resolved in 30 calendar days. 100% of all grievances must be resolved in 60 calendar days.

All notices containing the grievance resolution decisions shall be in writing.

The contractor shall send the notice of provider grievance resolution to the provider within five (5) business days following the date of resolution of the grievance.

How do I submit a FFS provider grievance?

The provider or their authorized representative may submit a provider grievance either orally or in writing. The contractor cannot require a written form from the provider or their representative for a grievance.

To submit a FFS grievance by telephone call:

• 1-800-766-9012 - Members
• 1-800-933-6593 - Providers

To submit a FFS grievance by fax send to:

• 785-267-7687

To submit a FFS grievance by mail send to:

KMAP/Kansas Medicaid Fiscal Agent
Grievance and Appeals Team
P.O. Box 3571
Topeka, KS 66601-3571

Is there a FFS Grievance Form?

No specific grievance form is required when submitting a provider grievance.

Is there a deadline for filing a FFS provider grievance?

Yes, a provider or their authorized representative must submit a provider grievance within one hundred and eighty (180) calendar days of the date of the incident being grieved.

What is the process once a FFS provider grievance has been submitted?

• The FFS grievance shall be resolved within 30 calendar days of receipt of the grievance from the FFS provider.
• The resolution of the grievance shall be communicated to the FFS provider by telephone or letter.

How do I submit a managed care provider reconsideration?

A provider or provider’s authorized representative may submit a request for reconsideration orally or in writing.

Is there a managed care reconsideration form?

• Healthy Blue
• Sunflower Appeal Form
• United Claims, Billings & Payments Page

Is there a deadline for filing a managed care provider reconsideration?

Yes, the timeframe within which a provider or provider’s authorized representative may submit a request for reconsideration with the contractor shall be 120 calendar days of the date of the notice of action, plus an additional three calendar days is allowed for mailing. The provider’s rights to appeal are preserved throughout the reconsideration process.

What is the process once a managed care provider reconsideration has been submitted?

• If a provider requests a reconsideration the contractor will review the claim and issue a notice of reconsideration resolution. There is no requirement for the contractors to review the reconsideration and issue the notice within a certain number of calendar days.
• A provider may terminate the reconsideration process and submit an appeal request within 63 calendar days of the date of the notice of action.
• If a provider does not submit an appeal within 63 calendar days of the date of the notice of action the provider must wait to receive the notice of reconsideration resolution before filing an appeal.

What documents do I need to submit for a managed care provider reconsideration?

Providers should follow the submission requirements for each MCO for reconsideration. Providers are encouraged to include the claim number, reason for the request, and supporting documentation with their request.

How do I submit a managed care provider appeal?

A provider or provider’s authorized representative may submit a request for appeal in writing.

To submit a managed care Appeal by mail send to:

Healthy Blue Kansas
Provider Appeals
P.O. Box 61599
Virginia Beach, VA 23466-1599

Sunflower
Quality Department
8325 Lenexa Drive, Suite 200
Lenexa, KS 66214

United
Grievances and Appeals
P.O. Box 31364
Salt Lake City, UT 84131-0364

To submit a managed care Appeal in person go to:

Healthy Blue
Not Available

Sunflower
Quality Department
8325 Lenexa Drive, Suite 200
Lenexa, KS 66214

United
Grievances and Appeals
P.O. Box 31364
Salt Lake City, UT 84131-0364

Is there a Managed Care Appeal Form?

• Healthy Blue - No required form
• Sunflower Provider Appeal Form
• United Provider Forms & References Page

Is there a deadline for filing a managed care provider appeal?

Yes, the time frame within which a provider or provider’s authorized representative may submit an appeal with the contractor shall be 60 calendar days of the date of the notice of action, plus an additional three calendar days is allowed for mailing.

What is the process once a managed care provider appeal has been submitted?

If a provider requests an appeal the contractor is required to acknowledge the appeal within 10 calendar days of receipt.

If a provider requests an appeal the contractor will review the appeal and issue a notice of appeal resolution. The contractor is required to review the appeal and issue the notice within 30 calendar days from the date of receipt.

What documents do I need to submit for a managed care provider appeal?

Providers should follow the submission requirements for each MCO for appeals. Providers are encouraged to include the claim number, reason for the request, and supporting documentation with their appeal request.

What is a managed care External Independent 3rd Party Review?

The EITPR will be available to providers who have received a denial by an MCO of authorization of a new healthcare service to an MCO member or a denial of a claim for reimbursement to the provider for a healthcare service to an MCO member.

How does a provider request an External Independent 3rd Party Review?

The provider must use the MCO’s EITPR Request Form to submit an EITPR request. The request should be sent to the address on the notice of appeal resolution.

The EITPR Request Forms may be found here:

• Healthy Blue EITPR Form
• Sunflower’s EITPR Form
• United’s EITPR Form

Is there a cost for an External Independent 3rd Party Review?

Yes. The external reviewer’s decision letter will direct the losing party of the review to pay the costs of the review to the third-party reviewer. If the MCO’s decision is upheld by the external reviewer, the requesting provider will be responsible for paying the costs of the review. If the MCO’s decision is reversed by the external reviewer, the MCO will be responsible for paying the costs of the review. View the costs for the review.

Is there a deadline for filing a provider External Independent 3rd Party Review?

Yes, the provider must submit an EITPR request to the MCO within 63 calendar days from the date of the appeal resolution notice.

What documents do I need to submit for my External Independent 3rd Party Review?

Providers may not submit additional documents with their request for external review. Providers must use each MCO’s EITPR Request Form to submit a request. On the request form, the provider must include all of the following:1) identify each specific issue the provider wants to dispute related to the adverse final decision issued by the MCO, 2) provide a detailed explanation of the reason the provider believes the MCO’s decision is incorrect, and 3) provide designated contact information, including name, mailing address, phone number, fax number and email address. The MCO will send the documents submitted by the provider during the appeal process to the external reviewer.

What happens once a provider External Independent 3rd Party Review has been submitted?

The MCO will acknowledge each written EITPR received from a provider in writing within 5 business days of receipt. If related to an authorization denial of a new healthcare service, the MCO must send a copy of the acknowledgement letter to the member. If the MCO fails to acknowledge the EITPR request, the MCO’s adverse decision is automatically reversed.

The MCO will send the documents submitted by the provider for the appeal to the Medicaid agency within 15 business days. If the MCO fails to send the documents within 15 business days, the MCO’s adverse decision is automatically reversed. The Medicaid agency will determine if the request meets all of the requirements for an EITPR. For requests that meet the requirements, the Medicaid agency will send the documents to the external reviewer. For requests that do not meet the requirements, the Medicaid agency will send a letter notifying the provider.

The external reviewer must complete their review of the provider’s request and send a letter with their review decision within 30 calendar days of receipt of the documentation forwarded by the Medicaid agency.

The MCO must issue a notice with the external reviewer’s decision to providers within 10 business days of receipt of the external reviewer’s decision. If related to an authorization denial of a new healthcare service, the MCO must send a copy of the notice with the external reviewer's decision to the member.

If the external reviewer upholds the MCO’s appeal decision, can a provider request a state fair hearing?

Yes, a provider must submit the request for a state fair hearing within 33 calendar days of the date of the MCO’s notice of external reviewer’s decision. If related to an authorization denial of a new healthcare service, the MCO must send a copy of the external reviewer’s decision to the member.

If the external reviewer upholds the MCO’s appeal decision regarding an authorization denial of a new healthcare service, can a member request a state fair hearing?

Yes, a member must submit the request for a state fair hearing within 33 calendar days of the date of the MCO’s notice of external reviewer’s decision.

Can a provider request a state fair hearing rather than requesting an External Independent 3rd Party Review?

Yes, a provider must submit the request for a state fair hearing within 123 calendar days of the date of the MCO’s notice of appeal resolution.

What is a managed care provider state fair hearing?

State fair hearing is defined as an administrative hearing involving the presentation of evidence and argument before a presiding officer from the Kansas Office of Administrative Hearings concerning an adverse benefit determination or an action. The presiding officer will hear the matter, determine the result, and issue a decision.

How do I submit a managed care provider state fair hearing request?

The provider or provider’s authorized representative’s state fair hearing request must be submitted in writing.

Providers - Request for Medicaid Fair Hearing

To submit a managed care state fair hearing by fax send to:

• (785) 296-4848 (Requests greater than 20 pages cannot be faxed).

To submit a managed care state fair hearing by mail send to:

Office of Administrative Hearings
1020 S. Kansas Ave.
Topeka, KS 66612

Is there a deadline for filing a managed care provider state fair hearing?

Yes, the provider or provider’s representative must submit a request for a state fair hearing within 123 calendar days from the date of the notice of the appeal resolution determination.

As of 1-1-20 the provider will have another opportunity to submit a request for a state fair hearing within 33 calendar days of the date of the notice containing the decision by the external independent third-party reviewer.

What is the process once a managed care provider state fair hearing request has been submitted?

The MCO will prepare the agency summary including notification to the provider that both the MCO and the Medicaid agency will be appearing at the state fair hearing.

The MCO will send the agency summary and addendums to the provider.

The Office of Administrative Hearings is responsible for the state fair hearing. The administrative hearing judge will usually issue his or her decision within 30 calendar days of the date of the hearing.

The Medicaid Agency is a party to the state fair hearing. The agency will be designated as the respondent in a state fair hearing for cases involving MCO decisions appealed to a state fair hearing by a provider. The Medicaid agency or another State agency authorized to administer that portion of the Kansas Medicaid Program will be designated as the respondent in those cases involving their area of administrative delegation.

The respondent or appellant to the state fair hearing may appeal the decision of the Initial Order issued by the Presiding Officer to the State Appeals Committee (SAC). SAC will review the Initial Order and issue a Final Order.

• If neither the respondent nor appellant requests a review of the Initial Order by SAC, the Initial Order will become the Final Order.
• The respondent or appellant may Appeal the Final Order to a district court.
• The respondent or appellant may also request a Reconsideration of the Final Order by the Secretary of KDHE-DHCF. There are filing time limits that are strictly enforced. The Initial and Final Order specify those time limits.

What documents do I need to submit for my managed care provider state fair hearing?

Send in your state fair hearing request form as soon as possible saying you want a hearing. Provide an explanation of why the decision/final action is unsatisfactory in your circumstances. Include a copy of the “notice” letter.

What else do I need to know? (Other managed care provider state fair hearing information.)

You may have an attorney represent you at the hearing. The attorney will be at your expense. If you hire an attorney, he or she must be licensed in the State of Kansas and enter their appearance on your behalf prior to the hearing.

• Deadlines for this information will come by letter from the Office of Administrative Hearings.

How do I submit a FFS provider state fair hearing request?

To submit a FFS state fair hearing by fax sent to:

• (785) 296-4848 (Requests greater than 20 pages cannot be faxed).

To submit a FFS state fair hearing by mail sent to:

Office of Administrative Hearings
1020 S. Kansas Ave.
Topeka, KS 66612

Is there a deadline for filing a FFS provider state fair hearing?

Yes, the FFS state fair hearing request must be filed within 33 calendar days from the date on the notice of action.

What is the process once a FFS provider state fair hearing request has been submitted?

The contractor will prepare the agency summary including notification to the provider that both the contractor and the Medicaid agency will be appearing at the state fair hearing.

The contractor will send the agency summary and addendums to the provider.

The Office of Administrative Hearings is responsible for the state fair hearing. The administrative hearing judge will usually issue his or her decision within 30 calendar days of the date of the hearing.

The Medicaid agency is a party to the state fair hearing. The Medicaid agency shall be designated as the Respondent in a state fair hearing for cases involving contractor decisions appealed to a state fair hearing by a provider. The Medicaid agency or another State agency authorized to administer that portion of the Kansas Medicaid Program will be designated as the Respondent in those cases involving their area of administrative delegation.

The Respondent or Appellant to the state fair hearing may appeal the decision of the Initial Order issued by the Presiding Officer to the State Appeals Committee (SAC). SAC will review the Initial Order and issue a Final Order.

• If neither the Respondent or Appellant requests a review of the Initial Orders by SAC, the Initial Order will become the Final Order.
• The Respondent or Appellant may Appeal the Final Order to a district court.
• The Respondent or Appellant also may request a Reconsideration of the Final Order by the Secretary of KDHE-DHCF. There are filing time limits that are strictly enforced. The Initial and Final Order specify those time limits.

What documents do I need to submit for my FFS provider state fair hearing?

Send in your state fair hearing request form as soon as possible saying you want a hearing. Provide an explanation of why the decision/final action is unsatisfactory in your circumstances. Include a copy of the “notice” letter.

Other FFS provider state fair hearing information

You may have an attorney represent you at the hearing. The attorney will be at your expense. If you hire an attorney, he or she must be licensed in the State of Kansas and enter their appearance on your behalf prior to the hearing.

• Deadlines for this information will come by letter from the Office of Administrative Hearings.

How do I submit a FFS provider state fair hearing request?

To submit a FFS state fair hearing by fax send to:

• (785) 296-4848 (Requests greater than 20 pages cannot be faxed).

To submit a FFS state fair hearing by mail send to:

Office of Administrative Hearings
1020 S. Kansas Ave.
Topeka, KS 66612

To submit a FFS state fair hearing in person go to:

Office of Administrative Hearings
1020 S. Kansas Ave.
Topeka, KS 66612

To submit a Withdrawal go to:

• Withdrawal of State Fair Hearing Request

Is there a deadline for filing a FFS provider state fair hearing?

Yes, the FFS state fair hearing request must be filed within 33 calendar days from the date on the notice of action.

What is the process once a FFS provider state fair hearing request has been submitted?

The Medicaid Agency will submit documents related to the decision about your services to OAH prior to the state fair hearing. You may also submit documents to OAH prior to the state fair hearing. OAH will schedule a state fair hearing about the Medicaid Agency's decision within one or two months of the date of your state fair hearing request. OAH must reach its decision usually within 30 calendar days of the state fair hearing date.

If you have an urgent medical condition, you may ask for an expedited (fast) hearing. You must provide medical documents that prove you have an urgent medical condition at the time you request a fast hearing. The Medicaid Agency will review medical documents and approve or deny your request. If approved, the hearing will be scheduled as soon as possible. If denied, your hearing request will be processed in the usual amount of time.

What documents do I need to submit for my FFS provider state fair hearing?

Full name, address, telephone number, a copy of the notice about which you are appealing. If your address changes during the state fair hearing process it is your responsibility to give that address change to OAH.

In the FFS state fair hearing process, you may provide information that shows why you believe that the Medicaid Agency did not follow the rules in processing your request for services.

Other FFS provider state fair hearing information.

You may have an attorney represent you at the hearing. The attorney will be at your expense. If you hire an attorney, he or she must be licensed in Kansas.

The most frequent mistake made by individuals during the process of preparing is failing to read the notices and documents issued as part of the state fair hearing process. The notices and documents will have deadlines. Read everything you receive very carefully.

How do I withdraw my request for a state fair hearing?

• Withdrawal of State Fair Hearing Request

May I bring an attorney or other representative to the hearing?

You may have an attorney represent you at the hearing. The attorney will be at your expense. If you hire an attorney, he or she must be licensed in Kansas. You may have a non-attorney represent you at the hearing.

Two legal assistance organizations that may provide help with a state fair hearing at no or low cost are:

Kansas Legal Services
Toll Free Phone: 1-800-723-6953 (application line)

Kansas Disability Rights Center
Toll Free Phone: 1-877-776-1541