Kansas Administrative Regulations

Agency 40. Insurance Department

Article 4. Accident and Health Insurance

40-4-42 Definitions; external review.

(a) ``Authorized representative'' means any of the following:

(1)  A person to whom the insured has given express written consent to represent the insured in an external review, unless the request for external review involves either of the following conditions:

(A)  A situation exists in which the insured has an emergency medical condition and the time frame for standard external review pursuant to K.A.R. 40-4-42d 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; or

(B)  express written consent cannot be obtained in a timely manner or is impracticable;

(2)  a person authorized by law to provide substituted consent for an insured; or

(3)  a family member of the insured or the insured's treating health care professional if the insured is unable to provide consent.

(b)  ``Business day'' is a day that is not a Saturday, Sunday, or legal holiday. A legal holiday is either of the following:

(1)  Any day designated as a holiday by the congress of the United States or by the Kansas legislature; or

(2)  any additional day that is designated by the governor in a particular year, on which state offices are closed in observance of a holiday or a holiday season.

(c)  ``Certification'' means a determination by an insurer or its designee utilization review organization that an admission, availability of care, continued stay, or other health care service has been reviewed and, based on the information provided, satisfies the insurer's requirements for medical necessity, appropriateness, health care setting, level of care, and effectiveness.

(d)  ``Clinical peer'' means a physician or other health care professional who holds a nonrestricted license in a state of the United States and, for a physician, who holds a current certification by a recognized American medical specialty board in the same or similar specialty that typically manages the medical condition, procedure, or treatment under review.

(e)  ``Clinical review criteria'' means the written screening procedures, decision abstracts, clinical protocols, and practice guidelines used by an insurer to determine the necessity and appropriateness of health care services.

(f)  ``Commissioner'' means the commissioner of insurance of the state of Kansas.

(g)  ``Covered benefits'' or ``benefits'' means those health care services to which an insured is entitled under the terms of a health benefit plan.

(h)  ``Discharge planning'' means the formal process for determining, before discharge from a facility, the coordination and management of the care that a patient receives following discharge from a facility.

(i)  ``Emergency services'' means health care items and services furnished or required to evaluate and treat an emergency medical condition as defined in L. 1999, Ch. 162, Sec. 6, and amendments thereto.

(j)  ``External review'' means an independent review of adverse decisions by an entity designated as an external review organization as defined in L. 1999, Ch. 162, Sec. 6, and amendments thereto.

(k)  ``Facility'' means an institution providing health care services or a health care setting, including the following:

(1)  Hospitals and other licensed inpatient centers;

(2)  ambulatory surgical or treatment centers;

(3)  skilled nursing centers;

(4)  residential treatment centers;

(5)  diagnostic, laboratory, and imaging centers; and

(6)  rehabilitation and other therapeutic health settings.

(l)  ``Final adverse decision'' means an adverse decision, as defined in L. 1999, Ch. 162, Sec. 6, and amendments thereto, that has been upheld by an insurer, or its designee utilization review organization, at the completion of the insured's internal grievance procedures. When the term ``adverse decision'' is used in K.A.R. 40-4-42 through 40-4-42g, it shall mean the same as ``final adverse decision.''

(m)  ``Health care professional'' means a physician or other health care practitioner licensed, accredited, or certified to perform specified health services consistent with state law.

(n)  ``Health care provider'' or ``provider'' means a health care professional or a facility.

(o)  ``Health care services'' means services for the diagnosis, prevention, treatment, cure, or relief of a health condition, illness, injury, or disease.

(p)  ``Prospective review'' means a utilization review conducted before an admission or a course of treatment.

(q)  ``Retrospective review'' means a utilization review of medical necessity conducted after services have been provided to a patient. This term shall not include the review of a claim that is limited to an evaluation of reimbursement levels, veracity of documentation, accuracy of coding, or adjudication for payment.

(r)  ``Utilization review'' means the evaluation of the necessity, appropriateness, and efficiency of the use of health care services, procedures, and facilities as defined in K.S.A. 40-22a01, et seq., and amendments thereto.

(s)  ``Utilization review organization'' means any entity that conducts a utilization review and determines the certification of an admission, extension of stay, or other health care service, as defined in K.S.A. 40-22a01, et seq., and amendments thereto.

This regulation shall take effect on and after January 1, 2000.

(Authorized by K.S.A. 40-103 and L. 1999, Ch. 162, § 9; implementing L. 1999, Ch. 162, § § 6-9; effective Jan. 7, 2000.)