Kan. Admin. Regs. § 129-5-10

Current through Register Vol. 43, No. 49, December 5, 2024

Section 129-5-10 - Definitions

Each of the following 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 payment act, K.S.A. 2014 Supp. 39-709f and amendments thereto.

(b) "Allowed amount" means any claim or portion of a claim that the provider and the managed care organization agree in good faith is correct and should be paid under the participating provider agreement with the managed care organization and under kancare program policies.

(c) "Claim" means any of the following:

(1) A bill for services;

(2) a line item of service; or

(3) all services for one beneficiary within a bill.

(d) "Clean claim" means any claim that can be processed without obtaining additional information from the provider of the service or from a third party. This term shall include any claim with errors originating in the state's claims system. This term shall not include any claim from a provider who is under investigation for fraud or abuse and any claim under review for medical necessity.

(e) "Day" means calendar day. If the 30th calendar day or the 90th calendar day falls on a weekend or a holiday, then the 30th calendar or 90th calendar day shall be deemed to occur on the following business day.

(f) "Managed care organization" means an entity that has contracted with the Kansas medical assistance program for the provision of managed care services to medicaid beneficiaries in Kansas.

(g) "Provider" means a health care provider that has entered into a participating provider agreement with a managed care organization.

(h) "Unpaid claim" means any claim that has not been paid by a managed care organization and meets one of the following conditions:

(1) Is not subject to a bona fide dispute as specified in K.A.R. 129-5-15 ; or

(2) has not yet been processed and denied by a managed care organization.

Kan. Admin. Regs. § 129-5-10

Authorized by and implementing K.S.A. 2014 Supp. 39-709f and 75-7403; adopted by Kansas Register Volume 34, No. 33; effective 8/28/2015.