Section 22-6-226

Review and approval of contracts; rules governing operation of integrated care networks.

(a) All provider contracts of an organization granted final certification as an integrated care network shall be subject to review and approval of the Medicaid Agency.

(b)(1) If a provider is dissatisfied with any term or provision of the agreement or contract offered by an integrated care network, the provider shall:

a. Seek redress with the integrated care network. In providing redress, an integrated care network shall afford the provider a review by a panel composed of a representative of an integrated care network, the same type of provider, and a representative of the citizens' advisory board appointed by the chair of the advisory board.

b. After seeking redress with an integrated care network, a provider or an integrated care network who remains dissatisfied may request a review of such disputed term or provision by the Medicaid Agency. The Medicaid Agency shall have 10 days to issue, in writing, its decision regarding the dispute.

c. If the provider or an integrated care network is dissatisfied with the decision of the Medicaid Agency, the provider or an integrated care network may file an appeal only in the Montgomery County Circuit Court within 30 days of the decision.

(c) The Medicaid Agency shall establish by rule requirements by which integrated care networks shall operate. In addition to the foregoing, the Medicaid Agency shall do all of the following:

(1) Establish by rule the criteria for certification of an integrated care network.

(2) Establish by rule the quality standards and minimum service delivery network requirements for an integrated care network to provide care to Medicaid beneficiaries.

(3) Establish by rule and implement quality assurance provisions for an integrated care network.

(4) Adopt and implement, at its discretion, requirements for an integrated care network concerning health information technology, data analytics, quality of care, and care quality improvement.

(5) Conduct or contract for financial audits of an integrated care network. The audits shall be based on requirements established by the Medicaid Agency by rule or established by law. The audit of an integrated care network shall be conducted at least every three years or more frequently if requested by the Medicaid Agency.

(6) Take any other action with respect to an integrated care network as may be required by federal Medicaid regulations or under terms and conditions imposed by the Centers for Medicare and Medicaid Services in order to assure that payments to an integrated care network qualify for federal matching funds.

(Act 2015-322, §8.)