The division measures, analyzes and reports health outcomes of Kentucky Medicaid members. The Division also oversees managed care organizations (MCOs) to ensure compliance with all federal and state regulations and contract provisions.
Third Party Review Process (SB20)
Senate Bill 20 established the right for a provider who has exhausted the written internal appeals process of a Medicaid managed care organization (MCO) to an external independent third-party review of the MCO final decision that denies, in whole or part, a health care service to an enrollee or a claim for reimbursement to a provider for a health care service rendered by the provider to an enrollee of the MCO. The legislation also afforded a provider or an MCO the right to an administrative hearing.
907 KAR 17:035 establishes the process for the external independent third-party review and 907 KAR 17:040 establishes the process for an administrative hearing.
Beginning with the dates of service on or after Dec. 1, 2016, providers may submit a request for an external independent third-party review within 60 calendar days of receiving a final decision from the MCO internal appeal process.
Provider Letter #A-102 Senate Bill 20
MCO Contact Information
2017 MCO Forum Presentations