Kansas Administrative Code

Uniformity of interpretation.The contracted staff of the department shall follow the interpretation provided by manuals, other policy materials, and official releases or communications from the secretary or the secretary’s designee. (Authorized by and implementing K.S.A. 2012 Sup…

Fees for providing copies. (a) Except as specified in subsection (b), the follow- ing fees may be charged for providing copies of department documents and records: (1)(A) For copies, a fee of $.25 per single-sided page; and (B) an additional fee not exceeding the actual cost of f…

Prior authorization. (a) Any medical service may be placed by the Kansas de- partment of health and environment, division of health care finance on the published list of ser- vices requiring prior authorization or precertifica- tion for any of the following reasons: (1) To ensure…

Definitions. Each of the follow- ing terms, when used in K.A.R. 129-5-10 through 129-5-21, shall have the meaning specified in this regulation: (a) “Act” means kancare prompt pay- ment act, K.S.A. 2014 Supp. 39-709f and amend- ments thereto. (b) “Allowed amount” means any claim o…

Scope of services for durable medical equipment, medical supplies, or- thotics, and prosthetics. (a) Selected durable medical equipment (DME) shall be available to each beneficiary, with the following limitations: (1) The DME shall be the most economical to meet the beneficiary’s…

Applicability. The act shall apply only to each claim with a date of service on or af- ter the effective date of the act, which was July 1, 2014. (Authorized by and implementing K.S.A. 2014 Supp. 39-709f and 75-7403; effective Aug. 28, 2015.)

Scope of federally qualified health center services. For purposes of this regulation, a federally qualified health center shall mean a community health center, federally quali- fied health center (FQHC) look-alike, or an urban Indian organization receiving funds under the In- dia…

Reimbursement for feder- ally qualified health center services. Reim- bursement shall not exceed the reasonable cost of federally qualified health center services and other ambulatory services covered under the Kansas medical assistance program. “Reasonable cost” shall consist of…

Cost reimbursement prin- ciples for federally qualified health center services and other ambulatory services. The medicare cost reimbursement principles contained in subparts A and G in 42 C.F.R. part 413, as re- vised on October 1, 2009 and hereby adopted by reference, and the c…

Electronic and paper claims. The act shall apply to each claim submitted under kancare to a managed care organization, wheth- er the claim is submitted in electronic or paper format. (Authorized by and implementing K.S.A. 2014 Supp. 39-709f and 75-7403; effective Aug. 28, 2015.)

Date claim is deemed to be re- ceived. If a provider submits a claim to a man- aged care organization by mail, the managed care organization shall be deemed to have received the claim no more than three business days after the claim was mailed, unless proven otherwise. If the pro…

Notice of denial or need for additional information; processing addition- al information; suspension of time periods. (a) If a claim is not a clean claim and cannot be either paid or processed and denied within 30 days after the managed care organization’s receipt of the claim, t…

Claims subject to bona fide dispute. An unpaid claim that is subject to a bona fide dispute, including any claim that a managed care organization has reason to believe is fraudu- lent and any claim undergoing a review for med- ical necessity, shall not be subject to the interest …

Partially paid claims. If a man- aged care organization pays a portion of a claim within the time limits specified in the act, then only the unpaid portion of that claim shall be sub- ject to the interest provisions of the act. (Autho- rized by and implementing K.S.A. 2014 Supp. …

Resubmitted claims. For each corrected claim resubmitted by a provider due to a provider error on the initial submission of the claim, the applicable 30-day or 90-day time lim- it for processing and full payment of the allowed amount or for processing and denial shall begin on re…

Date claim is deemed to be paid. Each claim shall be deemed paid on one of the following dates: (a) The date on which the managed care organization issued a check for pay- ment and any corresponding explanation of bene- fits to the provider; or (b) the date on which the managed c…

Interest on unpaid claims. (a) The principal amount due on which the interest payment shall be calculated shall be the allowed amount due but unpaid at the contracted rate for the service. All interest due under the act shall be applied only to the principal amount due as spec- i…

Retroactive rate, program, and policy changes and clarifications. A claim shall not be deemed to be an unpaid claim if a retro- active rate, program, or policy change creates an unpaid balance on a claim that the managed care organization has previously paid. (Authorized by and i…

Retroactive eligibility. If a provider submits a request for payment to a managed care organization before the pa- tient is determined by the state to be eligi- ble for medicaid, then the request shall not be deemed a claim under the act until the date on which the managed care o…

Filing limitations for medical claims. (a) Each provider shall submit all medical claims to the Kansas medical assistance program within 12 months from the date of service. (b) Any provider may resubmit a denied claim for payment to the Kansas medical assistance pro- gram if the …

Scope of and reimbursement for home-and community-based services for persons with traumatic brain injury. (a) The scope of allowable home-and community-based services (HCBS) for persons with traumatic brain injury shall consist of those services authorized by the applicable feder…

Scope of physician services. (a) Except as specified in subsection (b), the program shall cover medically necessary services recog- nized under Kansas law provided to program re- cipients by physicians who are licensed to practice medicine and surgery in the jurisdiction in which…

Determined eligibles; in- come standards. (a) Independent living arrange- ments. (1) The income standard for each person in an independent living arrangement shall be based on the total number of persons in the assistance plan as defined in K.A.R. 129-6-41 or 129-6-42. (2) The in…

General requirements for consideration of resources, including real property, personal property, and income. (a) For purposes of determining eligibility for med- ical assistance, legal title shall determine owner- ship. In the absence of legal title, possession shall determine ow…

Property exemption. (a) Own- ership of otherwise nonexempt real property or personal property shall not affect eligibility if the aggregate resource value is not in excess of $2,000 for one person or $3,000 for two or more persons, including the number of persons whose nonex- emp…

Real property. (a) Definitions. (1) “Home” shall mean the house or shelter in which the applicant or recipient is living, as well as the tract of land and contiguous tracts of land upon which the house and other improvements essential to the use or enjoyment of the home are locat…

Personal property. (a) Defini- tions. For purposes of this regulation, each of the following terms shall have the meaning specified in this regulation: (1) “Cash assets” means the following resources: (A) Cash surrender or loan values of life insur- ance policies; (B) investments…

Income. (a) Treatment of in- come for MAGI-based coverage groups. For purposes of this regulation, “prospective month- ly amount” shall mean an amount that is project- ed for purposes of determining an applicant’s or recipient’s monthly income. For those groups specified in K.A.R…

Applicable income. “Appli- cable income” shall mean the amount of earned and unearned income that is compared with the appropriate income standard to establish financial eligibility. (a) MAGI-based coverage groups. For those groups specified in K.A.R. 129-6-34(c)(1), all earned i…

Income exempt from consid- erationasincomeandasacashassetforMAGI- excepted groups. For those groups specified in K.A.R. 129-6-34(c)(2), exempted income shall be the following: (a) Grants, scholarships, and loans provided for educational purposes; (b)thevalueofbenefitsprovidedunde…

Income exempt as applicable income for MAGI-excepted groups. For those groups specified in K.A.R. 129-6-34(c)(2), the fol- lowing types of income shall be exempt as applica- ble income in the determination of eligibility: (a) Income-in-kind; (b) shelter cost participation payment…

Eligibility before the month of application. The eligibility of an applicant for the medical assistance program shall be deter- mined for the three months immediately before the month of application if the applicant requests this determination. (a) Automatic eligibles. The applic…

Correction and discontinu- ance of medical assistance. (a) Overpayments. Each recipient who receives an overpayment, whether caused by the department or the in- dividual, shall repay the amount of the over- payment, either by voluntary action or through administrative processes i…

Estate recovery. (a) Pursuant to K.S.A. 39-709 and amendments thereto and this regulation, each recipient’s real and personal property or estate shall be subject to the recovery of the cost of all medical assistance provided on the recipient’s behalf. By applying for and receiv- …

Presumptive eligibility. A pre- sumptive period of eligibility shall be provided if a qualified entity, designated by the department in accordance with K.A.R. 129-6-152, determines that the individual meets the presumptive eligibil- ity requirements as follows. (a) Pregnant women…

Presumptive eligibility when determined by qualified entities other than qualified hospitals. (a) Except for qualified hos- pitals pursuant to K.A.R. 129-6-153, each quali- fied entity shall be designated by the department to make determinations of presumptive eligibility as spec…

Presumptive eligibility when determined by qualified hospitals. (a) Each hospital that meets the following requirements shall be approved to make determinations of pre- sumptive eligibility as specified in K.A.R. 129-6- 151: (1) Participates as a medicaid provider in Kan- sas; (2…

Implementation of provisions specific to the ACA. The definitions in K.A.R. 129-6-34 and the provisions of K.A.R. 129-6-41, 129-6-42, 129-6-53, 129-6-54, 129-6-103, 129-6- 106(e), 129-6-110(a) and (b), 129-6-111(a) and (b), 129-6-112, and 129-6-113 shall apply to all eligibility …

Definitions; covered groups. (a) The terms defined in K.A.R. 129-1-1 shall be applicable to this article. In addition and for pur- poses of this article, each of the following terms shallhavethemeaningspecifiedinthisregulation, unless the context clearly indicates otherwise: (1)“…

Application process. (a) An ap- plication for medical assistance shall be submitted by an applicant, an adult who is in the applicant’s household or family, or another person authorized to act on the applicant’s behalf, except that an ap- plication on behalf of a person mandated …

Redetermination of eligibility process. (a) Each recipient shall provide the de- partment with information on the recipient’s cur- rent situation and have an opportunity to review the eligibility factors so that the department can redetermine the recipient’s continuing eligibilit…

(Authorized by K.S.A. 2005 Supp. 75-7412; implementing K.S.A. 2005 Supp. 75- 7412 and 75-7413, as amended by L. 2006, ch. 4, § 2; effective Aug. 11, 2006; revoked, T-129-10- 31-13, Nov. 1, 2013; revoked Feb. 28, 2014.)

Responsibilities of applicants and recipients. Each applicant or recipient shall perform the following: (a) Submit an application for medical assistance on a department-approved 812 KDHE—DIVISION OF HEALTH CARE FINANCE 129-6-41 form. Any applicant may withdraw the application bet…

Assistance planning for MAGI- based coverage groups. (a) The assistance plan for the groups described in K.A.R. 129-6-34(c)(1) shall consist of those persons in the household as determined in subsections (b) through (f). (b) For each person who is not claimed as a tax dependent b…

Assistance planning for MAGI- excepted coverage groups. (a) In independent living arrangements for the groups described in K.A.R. 129-6-34(c)(2), the following require- ments shall apply: (1) For any child who is not blind or disabled, the assistance plan shall consist of all chi…

Determined eligibles; gener- al eligibility factors. The general eligibility re- quirements in K.A.R. 129-6-51 through 129-6-60 and in K.A.R. 129-6-63 shall be eligibility factors applicable to determined eligibles, except as spec- ified in those regulations. Certain eligibility …

General eligibility require- ments. (a) Eligibility process. The determination of eligibility shall be based upon information pro- vided by the applicant or recipient, or on behalf of the applicant or recipient, as well as electronic data matches with other state and federal data…

Act on own behalf. (a) For pur- poses of this regulation, each of the following terms shall have the meaning specified in this subsection: (1) “Emancipated minor” means either of the following: (A) A person who is aged 16 or 17 and who is or has been married; or (B) a person who …

Financial eligibility for MAGI- based coverage groups. This regulation shall apply to all groups described in K.A.R. 129-6- 34(c)(1). (a) Definitions. For purposes of this reg- ulation, each of the following terms shall have the meaning specified in this regulation. (1) “Househol…

Financial eligibility for MAGI- excepted coverage groups. This regulation shall apply to all groups described in K.A.R. 129- 6-34(c)(2), except that subsections (c) and (d) of this regulation shall not apply to any medicare beneficiarywhomeetstherequirementsofK.A.R. 129-6-86 or t…