Kansas Administrative Regulations

Agency 40. Insurance Department

Article 4. Accident and Health Insurance

 

40-4-42g Exhaustion of internal review process.

 

(a)(1)  Except as provided in subsection (b) of this regulation, a request for external review pursuant to K.A.R. 40-4-42c and K.A.R. 40-4-42d shall not be made until the insured has exhausted the insurer's internal review process.

(2)  An insured shall be considered to have exhausted the insurer's internal review process for the purposes of this regulation if the insured or the insured's authorized representative meets either of the following criteria:

(A)  Has filed a request for internal review and received an adverse decision pursuant to the internal review procedures provided by the health insurance plan or insurer; or

(B)  except to the extent that the insured or the insured's authorized representative requested or agreed to a delay, has not received a final decision from the insurer within 60 days of seeking the internal review.

(b)(1)  A request for external review of an adverse decision may be made before the insured has exhausted the insurer's or health insurance plan's internal grievance procedures, if either of the following circumstances applies:

(A)  The insured has a emergency medical condition as defined in L. 1999, Ch. 162, Sec. 6, and amendments thereto.

(B)  The insurer agrees to waive the exhaustion requirement.

(2)  Notwithstanding paragraph (b)(1), an insured or the insured's authorized representative shall not make a request for an external review of an adverse decision involving a retrospective review decision made pursuant to K.S.A. 40-22a01 and L. 1999, Ch. 162, Secs. 6 through 9, and amendments thereto, until the insured has exhausted the insurer's internal review process.

(c)  If the requirement to exhaust the insurer's internal review process is waived under paragraph (b)(1)(B), the insured or the insured's authorized representative may request a standard external review pursuant to K.A.R. 40-4-42d.

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.)