Provider Grievances, Reconsiderations, Appeals, External Review & Fair Hearings

KanCare Provider Managed Care Organization (MCO)

If you are a KanCare Provider currently providing services to a member enrolled in a KanCare managed care organization (MCO) such as Aetna, Sunflower or United Health care, this applies to you.

Grievance


A managed care grievance is an expression of dissatisfaction about any matter other than an adverse decision.The grievance process is for KanCare providers who are dissatisfied about a matter involving a Managed Care Organization.

Reconsideration


A reconsideration is a review by a MCO of an action. Requesting a reconsideration is optional. The provider or provider’s authorized representative has the option to submit either a reconsideration request or an appeal request to the MCO following receipt of the MCO's notice of action. A provider may not request an external independent 3rd-party review after receiving a notice of reconsideration resolution. A provider may only request an external independent 3rd-party review after receiving a notice of appeal resolution.


Appeal


An appeal is a review by a MCO of an action. The appeal process is for KanCare providers involving a review of a denial of payment or a new healthcare service request by an MCO.

External Independent Third-Party Review (EITPR)


The EITPR is a review of 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. The reviewer will complete a review of the documents the provider submitted to the MCO for the MCO's appeal process, and issue a decision that affirms or reverses the MCO's appeal decision.

State Fair Hearing


The state fair hearing is done through the Office of Administrative Hearings (OAH) with the State of Kansas. It is an opportunity for the Provider to speak about the decision made by the MCO about  payment or a member's services. The Provider, MCO and the Medicaid agency meet before an impartial administrative law judge. He or she will issue an initial order based upon what is presented at the hearing.

Providers must complete the appeal process with their MCO prior to submitting a request for a state fair hearing.

Provider Fee for Service (FFS)

If you provided Medicaid services to members who do not have a managed care organization (MCO) such as Aetna, Sunflower or UnitedHealthcare, this applies to you (e.g., MediKan, QMB, SOBRA, Early Detection Works, PACE, etc.)

Grievance

A FFS  grievance is an expression of dissatisfaction about any matter including an adverse decision. The grievance process is for FFS providers who are dissatisfied about a FFS matter or adverse decision by the Medicaid Agency.

The state fair hearing is done through the Office of Administrative Hearings (OAH) with the State of Kansas. It is an opportunity for the Provider to speak about the decision made by the Medicaid Agency about  payment. The Provider and the Medicaid agency meet before an impartial administrative law judge. He or she will issue an initial order based upon what is presented at the hearing.