Requiring managed care organizations to provide an explanation of benefits to KanCare and CHIP enrollees.

Session of 2026
HOUSE BILL No. 2730
By Committee on Health and Human Services
Requested by Representative Bryce
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AN ACT concerning insurance; relating to medical assistance; requiring
managed care organizations to provide an explanation of benefits to
KanCare and CHIP enrollees; amending K.S.A. 39-709h and repealing
the existing section.
Be it enacted by the Legislature of the State of Kansas:
Section 1. K.S.A. 39-709h is hereby amended to read as follows: 39-
709h. (a) Upon request by a participating healthcare provider under the
Kansas medical assistance program, the secretary of health and
environment shall provide accurate and uniform patient encounter data that
complies with the federal health insurance portability and accountability
act of 1996 and applicable federal and state statutory and regulatory
requirements, including, but not limited to, the:
(1) Managed care organization claim number;
(2) patient medicaid identification number;
(3) patient name;
(4) type of claim;
(5) amount billed by revenue code and procedure code;
(6) managed care organization paid amount and paid date; and
(7) hospital patient account number.
(b) Upon receiving a request for patient encounter data pursuant to
subsection (a), the department of health and environment shall furnish to
the participating healthcare provider all requested information within 60
calendar days after receiving the request for data. The department of health
and environment may charge a reasonable fee for furnishing requested
data, including only the cost of any computer services, including staff time
required.
(c) (1) The secretary shall require any managed care organization
providing state medicaid or children's health insurance program services
under the Kansas medical assistance program to provide documentation to
a healthcare provider when the managed care organization denies any
portion of any claim for reimbursement submitted by the provider,
including a specific explanation of the reasons for denial and utilization of
remark codes, remittance advice and health insurance portability and
accountability act of 1996 standard denial reasons.
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(2) Each managed care organization shall offer quarterly in-person
training on remark codes and health insurance portability and
accountability act of 1996 standard denial reasons and any other denial
reasons or remark codes specific to the managed care organization.
(d) The secretary shall require managed care organizations providing
state medicaid or children's health insurance program services under the
Kansas medical assistance program to offer quarterly in-person education
regarding billing guidelines, reimbursement requirements and program
policies and procedures utilizing a format approved by the secretary and
incorporating information collected through semi-annual surveys of
participating healthcare providers.
(e) The secretary shall develop uniform standards to be utilized by
each managed care organization providing state medicaid or children's
health insurance program services under the Kansas medical assistance
program regarding:
(1) A standardized enrollment form and a uniform process for
credentialing and re-credentialing healthcare providers who have signed
contracts or participation agreements with any such managed care
organization;
(2) procedures, requirements, periodic review and reporting of
reductions in and limitations for prior authorization for healthcare services
and prescriptions;
(3) retrospective utilization review of re-admissions that complies
with any applicable federal statutory or regulatory requirements for the
medicaid program or the children's health insurance program, prohibiting
such reviews for any recipient of medical assistance who is re-admitted
with a related medical condition as an inpatient to a hospital more than 15
days after the recipient patient's discharge;
(4) a grievance, appeal and state fair hearing process that complies
with applicable federal and state statutory and regulatory procedure
requirements, including any statutory remedies for timely resolution of
grievances, appeals and state fair hearings, imposed upon managed care
organizations providing state medicaid or children's health insurance
program services; and
(5) requirements that each managed care organization, within 60
calendar days of receiving an appeal request, provide notice and resolve
100% of provider appeals, subject to remedies, including, but not limited
to, liquidated damages if provider appeals are not resolved within the
required time.
(f) The secretary shall procure the services of an independent auditor
for the purpose of reviewing, at least once per calendar year, a random
sample of all claims paid and denied by each managed care organization
and each managed care organization's subcontractors.
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(1) Each managed care organization and each managed care
organization's subcontractors shall be required to pay any claim that the
independent auditor determines to be incorrectly denied. Each managed
care organization and each managed care organization's subcontractors
may also be required to pay liquidated damages, as determined by the
department of health and environment.
(2) Each managed care organization and each managed care
organization's subcontractors shall be required to pay the cost of audits
conducted under this subsection.
(3) The provisions of this subsection shall expire on January 1, 2020.
(g) The secretary shall require each managed care organization to pay
100% of the state-established per diem rate to nursing facilities for current
medicaid-enrolled residents during any re-credentialing process caused by
a change in ownership of the nursing facility.
(h) On and after the effective date of this section, (g) A managed
care organization providing state medicaid or children's health insurance
program services under the Kansas medical assistance program shall not
discriminate against any licensed pharmacy or pharmacist located within
the geographic coverage area of the managed care organization that is
willing to meet the conditions for participation established by the Kansas
medical assistance program and to accept reasonable contract terms
offered by the managed care organization.
(h) On and after January 1, 2028, a managed care organization
providing state medicaid services under the Kansas state medical
assistance program or the children's health insurance program shall
provide an explanation of benefits either digitally or by postal mail to
enrollees after provision of healthcare services. Such explanation of
benefits shall include:
(1) The name and member identification number of the enrollee;
(2) the name of the healthcare provider or facility that provided
healthcare services and the date of the services provided;
(3) the billed amount;
(4) the allowed amount; and
(5) the amount paid by the Kansas medical assistance program.
(i) The secretary shall adopt rules and regulations as may be
necessary to implement the provisions of this section prior to January 1,
2018 2028.
Sec. 2. K.S.A. 39-709h is hereby repealed.
Sec. 3. This act shall take effect and be in force from and after its
publication in the statute book.
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