External Independent Third Party Review

Effective with denials issued by an MCO on and after January 1, 2020, providers are entitled to request an external independent third-party review (EITPR) of the MCO’s appeal decision. Providers must complete the MCO appeal process prior to requesting an EITPR. Providers may not request an EITPR for an MCO’s reconsideration decision. Members may not request an EITPR due to payment requirements.

Expand all

External Independent 3rd Party Review

What is a managed care External Independent 3rd Party Review?

The EITPR will be available to providers who have received a denial by an MCO of authorization of a new healthcare service to an MCO member or a denial of a claim for reimbursement to the provider for a healthcare service to an MCO member.
How does a provider request an External Independent 3rd Party Review?

The provider must use the MCO’s EITPR Request Form to submit an EITPR request. The request should be sent to the address on the notice of appeal resolution.
The EITPR Request Forms may be found here:
Aetna’s EITPR form: https://www.aetnabetterhealth.com/kansas/assets/pdf/providers/request_for_external_independent_third_party_review.pdf
Sunflower’s EITPR form: https://www.sunflowerhealthplan.com/content/dam/centene/sunflower/pdfs/EITPR-form.pdf
United’s EITPR form: https://www.uhcprovider.com/en/health-plans-by-state/kansas-health-plans/ks-comm-plan-home/ks-cp-forms-refs.html
Is there a cost for an External Independent 3rd Party Review?

Yes. The external reviewer’s decision letter will direct the losing party of the review to pay the costs of the review to the third-party reviewer. If the MCO’s decision is upheld by the external reviewer, the requesting provider will be responsible for paying the costs of the review. If the MCO’s decision is reversed by the external reviewer, the MCO will be responsible for paying the costs of the review. Costs for the review can be found here.
Is there a deadline for filing a provider External Independent 3rd Party Review?

Yes, the provider must submit an EITPR request to the MCO within 63 calendar days from the date of the appeal resolution notice.
What documents do I need to submit for my External Independent 3rd Party Review?

Providers may not submit additional documents with their request for external review. Providers must use each MCO’s EITPR Request Form to submit a request. On the request form, the provider must include all of the following:1) identify each specific issue the provider wants to dispute related to the adverse final decision issued by the MCO, 2) provide a detailed explanation of the reason the provider believes the MCO’s decision is incorrect, and 3) provide designated contact information, including name, mailing address, phone number, fax number and email address. The MCO will send the documents submitted by the provider during the appeal process to the external reviewer.
What happens once a provider External Independent 3rd Party Review has been submitted?

The MCO will acknowledge each written EITPR received from a provider in writing within 5 business days of receipt. If related to an authorization denial of a new healthcare service, the MCO must send a copy of the acknowledgement letter to the member. If the MCO fails to acknowledge the EITPR request, the MCO’s adverse decision is automatically reversed.

The MCO will send the documents submitted by the provider for the appeal to the Medicaid agency within 15 business days. If the MCO fails to send the documents within 15 business days, the MCO’s adverse decision is automatically reversed. The Medicaid agency will determine if the request meets all of the requirements for an EITPR. For requests that meet the requirements, the Medicaid agency will send the documents to the external reviewer. For requests that do not meet the requirements, the Medicaid agency will send a letter notifying the provider.

The external reviewer must complete their review of the provider’s request and send a letter with their review decision within 30 calendar days of receipt of the documentation forwarded by the Medicaid agency.

The MCO must issue a notice with the external reviewer’s decision to providers within 10 business days of receipt of the external reviewer’s decision. If related to an authorization denial of a new healthcare service, the MCO must send a copy of the notice with the external reviewer's decision to the member.
If the external reviewer upholds the MCO’s appeal decision, can a provider request a state fair hearing?

Yes, a provider must submit the request for a state fair hearing within 33 calendar days of the date of the MCO’s notice of external reviewer’s decision. If related to an authorization denial of a new healthcare service, the MCO must send a copy of the external reviewer’s decision to the member.
If the external reviewer upholds the MCO’s appeal decision regarding an authorization denial of a new healthcare service, can a member request a state fair hearing?

Yes, a member must submit the request for a state fair hearing within 33 calendar days of the date of the MCO’s notice of external reviewer’s decision.
Can a provider request a state fair hearing rather than requesting an External Independent 3rd Party Review?

Yes, a provider must submit the request for a state fair hearing within 123 calendar days of the date of the MCO’s notice of appeal resolution.