40-22a01 Utilization review organization act.
40-22a01. Utilization review organization act. This act shall be known and may be cited as the utilization review organization act. History: L. 1994, ch. 238, § 1; July 1.
40-22a02 Same; purpose.
40-22a02. Same; purpose. The legislature finds that in order to promote the delivery of quality health care services in a cost effective manner, it is necessary to encourage greater coordination between health care providers and those agencies performing utilization review of health care services. Effective standards for utilization review activities will protect patients while reducing […]
40-22a03 Same; definitions.
40-22a03. Same; definitions. For the purposes of this act: (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, […]
40-22a04 Utilization review organization act; standards; rules and regulations; certificate; conditions; annual fee; suspension or revocation of certificate.
40-22a04. Utilization review organization act; standards; rules and regulations; certificate; conditions; annual fee; suspension or revocation of certificate. (a) The commissioner shall adopt rules and regulations establishing standards governing the conduct of utilization review activities performed in this state or affecting residents or healthcare providers of this state by utilization review organizations. Unless granted an […]
40-22a05 Same; act not applicable to certain reviews and programs.
40-22a05. Same; act not applicable to certain reviews and programs. The utilization review organization act shall not apply to: (a) 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; (b) reviews conducted by any insurance company, health maintenance organization, […]
40-22a06 Same; certificate not required for certain review activities; certain provisions not applicable to certain organizations.
40-22a06. Same; certificate not required for certain review activities; certain provisions not applicable to certain organizations. (a) No certificate shall be required for utilization review activities conducted by or on behalf of: (1) An agency of the federal government; (2) a person, agency or utilization review organization acting on behalf of the federal government, but […]
40-22a07 Same; unlawful acts; penalties; prior notification requirements, limitations on.
40-22a07. Same; unlawful acts; penalties; prior notification requirements, limitations on. (a) (1) It is unlawful for any person or utilization review organization to perform utilization review activities in this state except in accordance with this act. (2) No utilization review organization nor any individual performing utilization review activities may agree to be compensated or receive […]
40-22a08 Same; examination by commissioner; expenses.
40-22a08. Same; examination by commissioner; expenses. Whenever the insurance commissioner deems it to be prudent for the benefit of the insureds, health care providers or insurers, the commissioner or any person designated by the commissioner may visit and examine the affairs of any utilization review organization to determine if the organization is in compliance with […]
40-22a09 Same; written procedures for utilization review; patient information confidential.
40-22a09. Same; written procedures for utilization review; patient information confidential. Each utilization review organization shall have written procedures for assuring that patient-specific information obtained during the process of utilization review will be: (a) Kept confidential in accordance with applicable federal and state laws; and (b) used solely for the purposes of utilization review, quality assurance, […]
40-22a09a Same; internal review procedure.
40-22a09a. Same; internal review procedure. (a) Every health insurance plan for which utilization review is performed shall include a description of the health insurance plan’s procedures for an insured to obtain an internal appeal or review of an adverse decision. This description shall include all applicable time periods, contact information, rights of the insured and […]
40-22a10 Same; patient information not subject to discovery or subpoena.
40-22a10. Same; patient information not subject to discovery or subpoena. Any records, charts or other information exchanged between a health care provider or patient and a utilization review organization shall not be subject to discovery, subpoena or other means of legal compulsion for their release to any person or entity and shall not be admissible […]
40-22a11 Same; rules and regulations.
40-22a11. Same; rules and regulations. The commissioner shall adopt necessary rules and regulations, not inconsistent with this act, for implementing the provisions of this act. History: L. 1994, ch. 238, § 11; July 1.
40-22a12 Same; severability.
40-22a12. Same; severability. If any provision or clause of this act or application thereof to any person or circumstance is held invalid, such invalidity shall not affect other provisions or applications of this act that can be given effect without the invalid provision or application. To this end, the provisions of this act are declared […]
40-22a13 External review of adverse health care decisions; definitions.
40-22a13. External review of adverse health care decisions; definitions. On and after July 1, 2011, for the purposes of K.S.A. 40-22a13 through 40-22a16, and amendments thereto: (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 […]
40-22a14 Same; exceptions; review procedure; confidentiality.
40-22a14. Same; exceptions; review procedure; confidentiality. On and after July 1, 2011: (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 […]
40-22a15 Same; insurance commissioner’s powers and duties; external review organizations, decisions, immunity from liability; fees, responsibility for.
40-22a15. Same; insurance commissioner’s powers and duties; external review organizations, decisions, immunity from liability; fees, responsibility for. On and after July 1, 2011: (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 […]
40-22a16 Same; judicial review; limitation on duplicative reviews; contractual services; rules and regulations.
40-22a16. Same; judicial review; limitation on duplicative reviews; contractual services; rules and regulations. On and after July 1, 2011: (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 […]