KANSAS INSURANCE
DEPARTMENT
K.A.R. 40-4-41b. Utilization review
organizations; requirements for collecting information. When
conducting routine prospective, concurrent, and retrospective utilization
reviews, each utilization review organization shall comply with the following
requirements:
(a)
Each utilization review
organization shall collect only the information necessary to certify the
admission, procedure or treatment, length of stay, and frequency or duration of
services. Utilization review organizations shall not perform any of the
following:
(1)
Routinely require health care
providers to supply numerically codified diagnoses or procedures to be
considered for certification. Utilization review organizations may ask for this
coding since, if it is known, its inclusion in the data collected increases the
effectiveness of the communication;
(2)
routinely request copies of clinical records
on all patients reviewed. During prospective and concurrent review, copies of
clinical records shall be required only when a difficulty develops in
certifying the necessity or appropriateness of the admission or extension of
stay, or the frequency or duration of service. In those cases, only the
necessary or pertinent sections of the record shall be required; or
(3)
request a review of all records on all
patients. This shall not preclude a request for copies of relevant clinical
records retrospectively for clinical review for a number of purposes, including
auditing the services provided, quality assurance, evaluation of compliance
with the terms of the health benefit plan or utilization review provisions.
With the exception of reviewing records associated with an appeal or with an
investigation of data discrepancies and unless otherwise provided for by
contract or law, health care providers shall be entitled to reimbursement for
the reasonable direct costs of duplicating requested records.
(b)
Each utilization review
organization shall accept required or requested information when submitted on
claim forms as authorized by K.S.A. 40-2253, and amendments thereto, and K.A.R.
40-4-40.
(c)
Each utilization review organization shall
limit its data requirements to the following elements unless otherwise
prescribed in these regulations:
(1)
Patient information, which shall
include the patient's name, address, telephone number, date of birth, gender,
social security number or patient identification number, the name of the
carrier or plan, including the plan type, and plan identification number;
(2)
enrollee information, which shall include the
enrollee's name, address, telephone number, social security number or employee
identification number, relation to patient, employer, health benefit plan,
group number or plan identification number, and other types of coverage available,
including workers compensation, auto, tricare (formerly known as champus),
medicare, or and other coverage;
(3)
health care provider
information, which shall include the provider's name, address, telephone
number, degree, specialty or certification status, and tax identification or
other identification number;
(4)
diagnosis or treatment information, which
shall include the primary diagnosis, secondary diagnosis, tertiary diagnosis,
multiaxial diagnosis, proposed or provided procedures or treatments, surgical
assistant requirement, anesthesia requirement, admission or service dates, the
procedure date, and the proposed length of stay;
(5)
clinical information sufficient to support the
appropriateness and level of service proposed or provided, and the name of a
contact person for detailed clinical information;
(6)
facility information, which shall include the
following:
(A)
The type of facility, including
an inpatient or outpatient facility, special unit, skilled nursing facility,
rehabilitation facility, office, or clinic;
(B)
the licensing or certification
status of the facility, including any applicable diagnostic-related group
exempt status; and
(C)
the facility's name, address, telephone
number, and tax identification number or other identification number;
(7)
concurrent or continued stay
review information, which shall include the following:
(A)
The number of additional days,
services, or procedures proposed;
(B)
a description of the reasons for the
extension, including clinical information sufficient to support the
appropriateness and level of service proposed;
(C)
information regarding the continued or changed
diagnoses; and
(D)
discharge planning;
(8)
information on admissions to
facilities other than medical care facilities, which shall include a history of
the present illness, the patient treatment plan and goals, the prognosis, staff
qualifications, and 24-hour availability of appropriate staff;
(9)
additional information for specific review
functions, which may include discharge planning or catastrophic case management
or, when if applicable, second opinion information sufficient to
support benefit plan requirements; and
(10)
other additional information when there is a
significant lack of agreement between the utilization review organization and
health care provider regarding the appropriateness of certification. “Significant
lack of agreement” shall mean that the utilization review organization
meets the following conditions:
(A)
Has tentatively determined,
through its professional staff, that a service cannot be certified;
(B)
has referred the case to a peer
clinical reviewer for review; and
(C)
for prospective and concurrent review, has
talked to or attempted to talk to the health care provider for further
information.
(d)
Each utilization review
organization shall share all clinical and demographic information on individual
patients among its various divisions to avoid duplicate requests for
information from enrollees or providers.
(e)
For prospective review and concurrent review,
each utilization review organization shall base its review determinations
solely on the medical information obtained by the utilization review
organization at the time of the review determination.
(f)
For retrospective review, each utilization
review organization shall base its review determinations solely on the medical
information available to the attending health care provider or ordering
provider at the time the medical care was provided.
(g)
Each utilization review organization shall
reverse its certification determination only if information provided to the
utilization review organization is materially different from that which was
reasonably available at the time of the original determination.
(h) Each utilization review organization shall accept
information from any reasonably reliable source that will assist in the
certification process. (Authorized
by K.S.A. 40-103, and K.S.A. 1999 Supp. 40-22a04, and
40-22a11; implementing K.S.A. 1999 Supp. 40-22a04 and 40-22a11;
effective, T-40-4-26-95, April 26, 1995; effective June 12, 1995; amended June
22, 2001; amended P-__________________.)