The Contract Compliance Branch provides contract oversight to assure that the Managed Care Organizations (MCOs) contracted with the Department for Medicaid Services (DMS) are compliant in all aspects to consistently provide reliable health care to Kentucky's Medicaid managed care members
Contract Compliance Branch staff is a liaison between the MCOs and DMS and a point of contact coordinating communications and connecting subject matter experts. Staff also partners with sister agencies such as DBHDID, DCBS and DPH on related Medicaid managed care issues providing oversight consistency in contractual activities.
Responsibilities of branch staff include:
- Specialization in all areas of contract compliance oversight
- Reviewing and assessing encounter reports for accuracy and imposing late fees and capitation withholdings when the records are noncompliant
- Issuing letters of concern and corrective action plans (CAP) when MCO activities are found contractually deficient
- Reviewing and approving CAPs when MCO activities are found to be substantially noncompliant with any material provision of a contract, such as breaches of member personal health information
- Approving MCO marketing and outreach documents for the Medicaid managed care members
- Attending community events to assure MCOs are adhering to marketing materials distribution in compliance with their contract
- Facilitating MCO encounter file submission and resubmission in conjunction with the Office of Administration and Technology Services and Hewlett Packard
- Conducting MCO provider network adequacy reviews
- Maintaining MCO contacts directories
- Conducting onsite and offsite contract compliance audits
- Facilitating monthly MCO operations meetings
- Assisting colleagues in MCO contractual obligations specifically required for program and project activities.
- Monitoring monthly, quarterly and annual MCO reports.
Provider Lock-In Information
The Lock-In Program was developed to identify, manage and monitor members who use Medicaid services at an amount or frequency that is not medically necessary in accordance with established utilization guidelines.
If a member is enrolled in a MCO, please contact the specific MCO for more information.
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 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
General Information