SUBPART D. MEDICAID MANAGED CARE
INDEPENDENT CLAIMS REVIEW PROCESS
§460.81. Right of providers to independent review; applicability
A. If a provider's claim is subject to an adverse determination evidenced in a remittance advice or other written or electronic notice from a managed care organization, then the provider shall have a right to an independent review of the adverse action taken by the managed care organization. Such independent review shall be governed by the provisions of this Subpart and any applicable rules and regulations promulgated by the department pursuant to the Administrative Procedure Act. The provisions of this Subpart shall not otherwise prohibit or limit any alternative legal or contractual remedy available to a provider to contest the partial or total denial of a claim for payment for healthcare services. Any contractual provision executed between a provider and a managed care organization which seeks to limit or otherwise impede the appeal process as set forth in this Subpart shall be null, void, and deemed to be contrary to the public policy of this state.
B. The provisions of this Subpart shall not apply to any adverse determination associated with a claim filed with a managed care organization prior to January 1, 2018, regardless of whether the claim is re-filed after that date. For all adverse determinations related to claims filed on or after January 1, 2018, the state shall not mandate that the provider and managed care organization resolve the claim payment dispute through arbitration.
C. An adverse determination involved in litigation or arbitration or not associated with a Medicaid enrollee shall not be eligible for independent review under the provisions of this Subpart.
Acts 2017, No. 349, §2.
Copyright ©2024 LegalFix. All rights reserved. LegalFix is not a law firm, is not licensed to practice law, and does not provide legal advice, services, or representation. The information on this website is an overview of the legal plans you can purchase—or that may be provided by your employer as an employee benefit or by your credit union or other membership group as a membership benefit.
LegalFix provides its members with easy access to affordable legal services through a network of independent law firms. LegalFix, its corporate entity, and its officers, directors, employees, agents, and contractors do not provide legal advice, services, or representation—directly or indirectly.
The articles and information on the site are not legal advice and should not be relied upon—they are for information purposes only. You should become a LegalFix member to get legal services from one of our network law firms.
You should not disclose confidential or potentially incriminating information to LegalFix—you should only communicate such information to your network law firm.
The benefits and legal services described in the LegalFix legal plans are not always available in all states or with all plans. See the legal plan Benefit Overview and the more comprehensive legal plan contract during checkout for coverage details in your state.
Use of this website, the purchase of legal plans, and access to the LegalFix networks of law firms are subject to the LegalFix Terms of Service and Privacy Policy.