History: L. 1994, ch. 238, § 1; July 1.
History: L. 1994, ch. 238, § 2; July 1.
(a) "Commissioner" means the commissioner of insurance.
(b) "Utilization review" means the evaluation of the necessity, appropriateness and efficiency of the use of health care services, procedures and facilities.
(c) "Utilization review organization" means any entity which conducts utilization review and determines certification of an admission, extension of stay or other health care service.
(d) "Health care provider" means a licensed medical care facility, a licensed health maintenance organization, or a person licensed or registered to engage in an occupation which renders health care services.
History: L. 1994, ch. 238, § 3; July 1.
(b) The commissioner shall not issue a certificate to a utilization review organization until the applicant:
(1) Files a formal application for certification in such form and detail as required by the commissioner and such application has been executed under oath by the chief executive officer of the applicant;
(2) files with the commissioner a certified copy of its charter or articles of incorporation and bylaws, if any;
(3) states the location of the office or offices of the utilization review organization where utilization review affecting residents or health care providers of this state will be principally performed;
(4) provides a summary of the qualifications and experience of persons performing utilization review affecting the persons and at the locations identified pursuant to paragraph (3);
(5) makes payment of a certification fee of $100 to the commission; and
(6) provides such other information or documentation as the commissioner requires.
(c) Certificates issued by the commissioner pursuant to this act shall remain effective until suspended, surrendered or revoked subject to payment of an annual continuation fee of $50.
(d) The commissioner with the advice of the advisory committee may suspend or revoke the certificate or any exemption from certification requirements upon determination that the interests of Kansas insureds are not being properly served under such certificate or exemption. Any such action shall be taken only after a hearing conducted in accordance with the provisions of the Kansas administrative procedure act.
History: L. 1994, ch. 238, § 4; July 1.
(1) The commissioner, or the designee of the commissioner, who shall be the chairperson;
(2) one member appointed from the public at large;
(3) four members who are representatives of utilization review organizations; and
(4) seven members who are representatives of health care providers, one of which shall be a representative of a Kansas hospital, and two of which shall be persons licensed to practice medicine and surgery in Kansas.
(b) Members of the advisory committee shall be appointed for a term of three years, except that the first term of office of two members representing utilization review organizations and two members representing health care providers shall be for a term of two years, and the first term for two members representing health care providers and one member representing utilization review organizations shall be for a term of one year.
(c) The advisory committee shall be attached to the insurance department, and all administrative functions of the advisory committee shall be under the direction and supervision of the commissioner. Within available appropriations therefor, members of the advisory committee shall be paid subsistence allowances, mileage and other expenses as provided in subsection (e) of K.S.A. 75-3223 and amendments thereto.
(d) Before adopting rules and regulations to carry out the provisions of this act, the commissioner with the advice of the advisory committee shall:
(1) Establish utilization review standards which provide for uniformity in the procedures for interaction between utilization review organizations and health care providers, payors and consumers of health care;
(2) establish utilization review procedures that prevent unnecessary and inappropriate disruption to the health care delivery system;
(3) strive to achieve an efficient process for the certification of utilization review organizations; and
(4) specify the kinds of insurance or types of insurance products to which the standards apply and the scope of such application.
(e) This act shall not apply to:
(1) Utilization review of health care services provided to patients under the authority of the Kansas workers compensation act (K.S.A. 44-501 et seq., and amendments thereto);
(2) reviews conducted by any insurance company, health maintenance organization, prepaid service plan, group-funded self-insured plan or similar entity solely for the purpose of determining compliance with the specific terms and conditions of an insurance policy, agreement or contract as a part of the normal claim settlement process; or
(3) any medical programs operated by the secretary of social and rehabilitation services or any entity to the extent it is acting under contract with the secretary.
History: L. 1994, ch. 238, § 5; July 1.
(1) An agency of the federal government;
(2) a person, agency or utilization review organization acting on behalf of the federal government, but only to the extent such person, agency or organization is providing services under federal regulation;
(3) a federally qualified health maintenance organization authorized to transact business in Kansas which is administering a quality assurance program and performing utilization review activities for its own members as required by 42 U.S.C. 300e(c)(8) and 42 U.S.C. 300e(c)(6) respectively;
(4) a person employed or used by a utilization review organization authorized to perform utilization review in Kansas, including, but not limited to, individual nurses and other health care providers. This exemption shall not apply with respect to individual persons performing utilization review activities in conjunction with any insurance contract or health benefit plan pursuant to a direct contractual relationship with a health maintenance organization, group-funded self-insurance plan or insurance company;
(5) a health benefit plan that is self-insured and qualified under the federal employee retirement income security act of 1974 as amended;
(6) hospitals, home health agencies, clinics, private health care provider offices or any other authorized health care facility or entity conducting general, in-house utilization review unless such review is for the purpose of approving or denying payment for hospital or medical services in a particular case; or
(7) utilization review organizations conducting utilization review only with respect to mental health, chemical dependency, chiropractic, optometric, podiatric, dental or any other health care service or services other than the practice of medicine and surgery, until utilization review standards governing such treatment or service are incorporated in rules and regulations adopted pursuant to K.S.A. 40-22a04, and amendments thereto.
(b) The provisions of K.S.A. 40-22a04 (b)(2), (3), (4), (5), (6) and subsection (c), and amendments thereto, shall not apply to:
(1) Utilization review organizations accredited by and adhering to the national utilization review standards approved by the American accreditation health care commission; or
(2) such other utilization review organizations as the advisory committee may recommend and the commissioner approves.
History: L. 1994, ch. 238, § 6; L. 1998, ch. 14, § 1; July 1.
(2) No utilization review organization nor any individual performing utilization review activities may agree to be compensated or receive compensation which is contingent in any way upon frequency of certification denials, costs avoided by denial or reduction in payment of claims or other results which may be adverse to the needs of the patient as determined by the attending health care provider.
(b) When the commissioner has reason to believe a utilization review organization subject to this act has been or is engaged in any conduct which violates this act or any rules and regulations adopted pursuant to K.S.A. 40-22a11, the commissioner, after a hearing conducted in accordance with the Kansas administrative procedure act, may:
(1) Issue and cause to be served upon the utilization review organization an order requiring such organization to cease and desist from engaging in such violations;
(2) suspend or revoke the utilization review organization's certificate to perform utilization review affecting residents of this state;
(3) assess a monetary penalty of not less than $500 and not more than $1,000 for each violation; or
(4) apply any combination of the above provisions as the commissioner, by written order, deems appropriate.
History: L. 1994, ch. 238, § 7; July 1.
Any person or entity examined pursuant to the provisions of this section shall pay the reasonable and proper charges incurred for such examination, including the actual expenses of the insurance commissioner or the expenses and compensation of the commissioner's authorized representative and the expenses and compensation of assistants and examiners employed therein.
History: L. 1994, ch. 238, § 8; July 1.
(a) Kept confidential in accordance with applicable federal and state laws; and
(b) used solely for the purposes of utilization review, quality assurance, discharge planning and catastrophic case management.
History: L. 1994, ch. 238, § 9; July 1.
(b) If the health insurance plan contains a provision for two levels of internal appeal or review of a health care decision which is adverse to the insured, the health insurance plan shall allow the insured to voluntarily waive such insured's right to the second internal appeal or review. Such waiver shall be made in writing to the health insurance plan and shall constitute the exhaustion of all available internal appeal or review procedures within the meaning of subsection (d) of K.S.A. 40-22a14 and amendments thereto.
(c) If an insured elects to request the second internal appeal or review of a health care decision which is adverse to the insured, the insured shall have the right to appear in person before a designated representative or representatives of the health insurance plan or utilization review organization at the second internal appeal or review meeting. If a majority of the designated representatives of the health plan or utilization review organization who will be deciding the second internal appeal or review cannot be present in person, by telephone or by other electronic means, at least one of those designated representatives who will be deciding the second internal appeal or review shall be a physician and shall be present in person, by telephone or by other electronic means. No physician or other health care provider serving as a reviewer in an internal appeal or review of an adverse decision shall be liable in damages to the insured or the health insurance plan for any opinion rendered as part of the internal appeal or review.
(d) All second internal appeals or reviews shall provide that the insured has a right to:
(1) Receive from the health insurance plan or utilization review organization, upon request, copies of all documents, records and other information that are not confidential or privileged relevant to the insured's request for benefits;
(2) have a reasonable and adequate amount of time to present the insured's case to a designated representative or representatives of the health insurance plan or utilization review organization who will be deciding the second internal appeal or review;
(3) submit written comments, documents, records and other material relating to the request for benefits for the second internal appeal or review panel to consider when conducting the second internal appeal or review both before and, if applicable, at the second internal appeal or review meeting;
(4) prior to or during the second internal appeal or review meeting ask questions relevant to the subject matter of the internal appeal or review of any representative of the health insurance plan or utilization review organization serving on the internal appeal or review panel provided that such representative may respond verbally if the question is asked in person during an insured's appearance before the internal appeal or review panel or in writing if the questions are asked in writing, not more than 30 days from receipt of such written questions;
(5) be assisted or represented at the second internal appeal or review meeting by an individual or individuals of the insured's choice; and
(6) record the proceedings of the second internal appeal or review meeting at the expense of the insured.
(e) An insured, or the insured's authorized representative, wishing to request to appear in person before the second internal appeal or review panel consisting of the health insurance plan's or utilization review organization's designated representative or representatives shall make the request to the health insurance plan or utilization review organization within five working days before the date of the scheduled review meeting except that in the case of an emergency medical condition, such request must be made no less than 24 hours prior to the scheduled review meeting.
(f) The health insurance plan or utilization review organization shall provide the insured a written decision setting forth the relevant facts and conclusions supporting its decision within:
(1) Seventy-two hours if the second internal appeal or review involves an emergency medical condition as defined by subsection (b) of K.S.A. 40-22a13 and amendments thereto;
(2) fifteen business days if the second internal appeal or review involves a pre-service claim; and
(3) thirty days if the second internal appeal or review involves a post-service claim.
(g) For the purposes of this section:
(1) "Health insurance plan" shall have the meaning ascribed to it in K.S.A. 40-22a13 and amendments thereto.
(2) "Insured" shall have the meaning ascribed to it in K.S.A. 40-22a13 and amendments thereto.
(3) "Insurer" shall have the meaning ascribed to it in K.S.A. 40-22a13 and amendments thereto.
(4) "Adverse decision" shall have the meaning ascribed to it in K.S.A. 40-22a13 and amendments thereto.
(5) "Pre-service claim" means a request for a claims decision when prior authorization of services is required.
(6) "Post-service claim" means a request for a claims decision for services that have already been provided.
(h) This section shall be a part of and supplemental to the utilization review act.
History: L. 2006, ch. 127, § 1; July 1.
History: L. 1994, ch. 238, § 10; July 1.
History: L. 1994, ch. 238, § 11; July 1.
History: L. 1994, ch. 238, § 12; July 1.
(a) "Adverse decision" means a utilization review determination by a third-party administrator, a health insurance plan, an insurer or a health care provider acting on behalf of an insured that a proposed or delivered health care service which would otherwise be covered under an insured's contract is not or was not medically necessary or the health care treatment has been determined to be experimental or investigational and, (1) if the requested service is provided in a manner that leaves the insured with a financial obligation to the provider or providers of such services, or (2) the adverse decision is the reason for the insured not receiving the requested services.
(b) "Emergency medical condition" means the sudden, and at the time, unexpected onset of a health condition that requires immediate medical attention, where failure to provide medical attention would result in a serious impairment to bodily functions, serious dysfunction of a bodily organ or part or would place a person's health in serious jeopardy.
(c) "External review organization" means an entity that conducts independent external reviews of adverse decisions pursuant to a contract with the commissioner. Such entity shall have experience serving as the external quality review organization in health programs administered by the state of Kansas, or be a nationally accredited external review organization which utilizes health care providers actively engaged in the practice of their profession in the state of Kansas who are qualified and credentialed with respect to the health care service review. In the event no Kansas providers are qualified and credentialed with respect to the review of any case, the external review organization shall have the discretion to employ health care providers who actively engage in such health care provider's practice outside the state of Kansas.
(d) "Health insurance plan" means any hospital or medical expense policy, health, hospital or medical service corporation contract, and a plan provided by a municipal group-funded pool, or a health maintenance organization contract offered by an employer or any certificate issued under any such policies, contracts or plans.
(e) "Insured" means the beneficiary of any health insurance company, fraternal benefit society, health maintenance organization, nonprofit hospital and medical service corporation, municipal group funded pool, and the self-funded coverage established by the state of Kansas, or any hospital or medical expense, health, hospital or medical service corporation contract or a plan provided by a municipal group-funded pool.
(f) "Insurer" means any health insurance company, fraternal benefit society, health maintenance organization, nonprofit hospital and medical service corporation, provider sponsored organizations, municipal group-funded pool and the self-funded coverage established by the state of Kansas for its employees.
History: L. 1999, ch. 162, § 6; July 1.
(a) The provisions of K.S.A. 40-22a13 through 40-22a16 and amendments thereto shall not apply to any policy or certificate which provides coverage for any specified disease, specified accident or accident only coverage, credit, dental, disability income, hospital indemnity, long-term care insurance as defined by K.S.A. 40-227, and amendments thereto, vision care or any other limited supplemental benefit nor to any medicare supplement policy of insurance as defined by the commissioner of insurance by rule and regulation, coverage under a plan through medicare, medicaid, or the federal employees health benefits program, any coverage issues as a supplement to liability insurance, workers compensation or similar insurance, automobile medical-payment insurance or any insurance under which benefits are payable with or without regard to fault, whether written on a group, blanket or individual basis.
(b) The right to external review under K.S.A. 40-22a13 through 40-22a16, and amendments thereto, shall not be construed to change the terms of coverage under a health insurance plan or insurance policy.
(c) The insurer or health insurance plan shall provide written notice to the insured of a final adverse decision and the opportunity for requesting an external review.
(d) The insured has the right to request an independent external review of an adverse decision by a health insurance plan or insurer when: (1) The insured has exhausted all available internal review procedures provided by the health insurance plan or insurer, unless the insured has an emergency medical condition, in which case an expedited procedure is used; or (2) the insured has not received a final decision from the insurer within 60 days of seeking the internal review, except to the extent that the delay was requested by the insured.
(e) Within 90 days of receipt of an adverse decision by a health insurance plan or an insurer, any request for external review shall be made in writing to the commissioner from the following persons: (1) The insured; (2) the treating physician or health care provider acting on behalf on [of] the insured with written authorization from the insured; or (3) a legally authorized designee of the insured.
(f) The insured shall provide all information in the possession of the insured pertaining to the adverse decision in order for the commissioner to make a preliminary determination for an external review. The insured also shall provide the commissioner with an appeal form, and a fully executed release for the commissioner and the external review organization to obtain any necessary medical records from the insurer or health insurance plan and any other relevant provider.
(g) In responding to the commissioner, the insurer or health insurance plan shall provide a copy of the adverse decision given to the insured and all medical and other records pertaining to the insured's claim within five business days of the request of the commissioner.
(h) The confidentiality of any medical information submitted by the insured, on behalf of the insured, insurer or health insurance plan, shall be maintained pursuant to applicable state and federal laws.
History: L. 1999, ch. 162, § 7; July 1.
(a) The commissioner shall:
(1) Negotiate contracts with external review organizations which are eligible to conduct independent review of the adverse decision by a health insurance plan or insurer;
(2) allow the insurer or the health insurance plan, an insured or treating physician or health care provider acting on behalf of the insured, or legally authorized designee filing a request for external review to provide additional written information as may be relevant for the commissioner to make a final decision on whether the request qualified for external review;
(3) make a decision on a request for external review within 10 business days after receiving all necessary information;
(4) notify the insured and treating physician or health care provider acting on behalf of the insured, or legally authorized designee, and insurer or health insurance plan in writing that a request for external review will or will not be granted; and
(5) design and implement an expedited procedure for use in an emergency medical condition for purposes of the external review organization rendering a decision.
(b) The external review organization as defined in subsection (c) of K.S.A. 40-22a13, and amendments thereto, shall provide that all reviews completed pursuant to K.S.A. 40-22a13 through 40-22a16, and amendments thereto, are conducted by qualified and credentialed health care providers with respect to the health care service under review and who have no conflict of interest relating to the performance of the external review organization's duties in K.S.A. 40-22a13 through 40-22a16, and amendments thereto.
(c) The external review organization shall issue a written decision to the insured and concurrently send a copy of such decision to the commissioner including the basis and rationale for its decision within 30 business days. The standard of review shall be whether the health care service denied by the insurer or health insurance plan was medically necessary under the terms of the insured's contract. In reviews regarding experimental or investigational treatment, the standard of review shall be whether the health care service denied by the insurer or health insurance plan was covered or excluded from coverage under the terms of the insured's contract.
(d) The external review organization shall provide expedited resolution when an emergency medical condition exists, and shall resolve all issues within seven business days.
(e) The external review organization shall maintain and report such data as may be required by the commissioner in order to assess the effectiveness of the external review process.
(f) No external review organization nor any individual working on behalf of such organization shall be liable in damages to any insured, health insurance plan or insurer for any opinion rendered as part of an external review conducted pursuant to K.S.A. 40-22a13 through 40-22a16, and amendments thereto.
(g) The external review organization shall maintain confidentiality of the medical records of the insured in accordance to state and federal law.
History: L. 1999, ch. 162, § 8; July 1.
(a) The decision of the external review organization may be reviewed directly by the district court at the request of either the insured, insurer or health insurance plan. The review by the district court shall be de novo. The decision of the external review organization shall not preclude the insured, insurer or health insurance plan from exercising other available remedies applicable under state or federal law. Seeking a review by the district court or any other available remedies exercised by the insured, insurer or health insurance plan after the decision of the external review organization will not stay the external review organization's decision as to the payment or provision of services to be rendered during the pendency of the review by the insurer or health insurance plan. All material used in an external review and the decision of the external review organization as a result of the external review shall be deemed admissible in any subsequent litigation.
(b) In no event shall more than one external review be available during the same year for any request arising out of the same set of facts. An insured may not pursue, either concurrently or sequentially, an external review process under both a federal and state law. In the event external review processes are available pursuant to federal law and this act, the insured shall have the option of designating which external review process will be utilized.
(c) The commissioner of insurance is hereby authorized to negotiate and enter into contracts necessary to perform the duties required by K.S.A. 40-22a13 through 40-22a16, and amendments thereto.
(d) The commissioner of insurance shall adopt rules and regulations necessary to carry out the purposes of K.S.A. 40-22a13 through 40-22a16, and amendments thereto. The rules and regulations shall ensure that the commissioner is able to provide for an effective and efficient external review of health care services.
History: L. 1999, ch. 162, § 9; July 1.