Navigating KanCare Grievances and Appeals

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PDF - Your Guide to the KanCare Grievances & Appeals Process

PDF - Everything You Wanted to Know about the KanCare Grievances & Appeals Process (full 4-page guide)

Your Guide to the KanCare Grievances & Appeals Process

The process of submitting KanCare grievances and appeals with Medicaid and Managed Care Organizations (MCOs) can be confusing. This document offers simple steps to understand how you can: 

  • - Work with your MCO to get what you need
  • - Use the MCO grievance process as a step to get what you need 
  • - Appeal to the Office of Administrative Hearings (OAH)

Start Here: Getting What You Need from Your MCO

In most cases, when trying to get a service or piece of equipment from an MCO, you should talk to your doctor first about what you need and why. Your doctor may send records or a referral to document what you are asking for is medically necessary. 

The MCO then reviews your request to decide if what you're asking for is covered by Medicaid, medically necessary, and if it will be approved. 

If you're unhappy with a service, you have the right to file a grievance! If your MCO denies, stops, or reduces a service - you have rights to challenge it!

Grievances: When You're Unhappy (Not for Denials)

A grievance is filed with your MCO. You can file a grievance if you're unhappy with care, service, or treatment - not with a denial of benefits or reduction in services. 

Examples of a Grievance: 

  • - Poor quality services or poor behavior from staff 
  • - Someone disrespected your rights or dignity
  • - You got a bill from a provider that your MCO should have paid

How to File a Grievance:

  • - Call or write your MCO (no special form is needed and cannot be required).

The MCO must acknowledge the grievance within 10 calendar days of receiving it and resolve the grievance within 30 calendar days of receiving it. 

Appeals: When Your Service is Denied, Cut, or Stopped

You can appeal when you want a review of a decision the MCO made that denies or limits a service or equipment, reduces or ends a service you already get, or delays approving a service for too long.

To Appeal: 

  • - Send your appeal within 63 days of the denial notice
  • - You can call or write the MCO to submit an appeal - but appealing in writing is better (proof!)
  • - The MCO must confirm receipt of your appeal within 5 days and resolve the appeal within 30 days 
  • - Consider including a short letter from your doctor supporting your position, explaining what changed, why that’s a problem, and how it affects your health or independence. Also consider including copies of your care plan or denial letter, if available.

Services While You Appeal: For Non-HCBS services, you must ask your MCO to continue your services within 10 days of the denial notice. If you appeal on time, the MCO must continue services until your appeal decision. Note that you may have to pay for the continued services if you lose the appeal or state fair hearing decision. For HCBS services, your services will automatically continue for 63 days from the date of the denial notice, to allow you time to appeal. You will not have to pay for continued services if you lose the appeal or state fair hearing decision, unless there is fraud.

State Fair Hearings (Office of Administrative Hearings - OAH)

If your MCO denies your appeal, you can ask for a  state fair hearing with an independent judge.

Grievances: 

  1. Submit your hearing request in writing within 123 days of the MCO’s appeal decision. Make sure you read every notice you receive very carefully because deadlines are firm!
  2. You'll get a hearing date (usually 1-2 months later).
  3. You, your MCO, and state representatives may attend and share evidence. You may hire an attorney to represent you at your own cost. 
  4. The judge issues a written decision, usually within 30 days after the hearing.

Summary 

Table summarizing the information described above. The Grievance step is to complain about customer service or quality. You have 10 days for MCO to respond and 30 days for MCO to resolve. The MCO Appeal step is to challenge a denial, stop, or cut in services. You have 63 days to file (from the date of the notice). Services continue if requested within 10 days from the mailing date on the notice. The State Fair Hearing (OAH) step is to ask a judge to review your case after your appeal was denied. You have 123 days to file (from the date of the appeal). HCBS services continue for 123 days.

Want to learn more? View DRC's full 4-page guide here.

Navigating KanCare Grievances and Appeals