KANSAS INSURANCE
DEPARTMENT
K.A.R. 40-4-41c. Utilization review
organizations; written procedures. Each utilization review
organization shall maintain the following written procedures: (a) Written
procedures to assure ensure that reviews and second opinions are
conducted in a timely manner shall be maintained as follows:
(1)
Each utilization review
organization shall make prospective or concurrent certification determinations
within two working days of receipt of the necessary information on a proposed
admission or service requiring a review determination.
Collection of the necessary information may necessitate a discussion with the
health care provider or, based on the requirements of the health benefit plan,
may involve a completed second opinion review.
(2) The
Each utilization review organization may review ongoing inpatient stays,
but shall not routinely conduct a daily review of all these stays. The
frequency of the review for extension of the initial determination may vary,
based on the severity or complexity of the patient's condition or on necessary
treatment and discharge planning activity.
(3) Each
utilization review organization shall make retrospective determinations, in the
absence of any contractual agreement, within 30 days of the receipt of the
necessary information. Each utilization review organization shall issue a
determination for prospective review according to either of the following
deadlines:
(A) Within
72 hours of the request for a utilization management decision if the case
involves urgent care, excluding intermediate Saturdays, Sundays, and legal
holidays; or
(B) within
15 days, as computed in K.S.A. 60-206 and amendments thereto, of the request
for a utilization management determination involving nonurgent care. This period may be extended once by the
utilization review organization for up to 15 days if the extension is necessary
due to matters beyond the control of the utilization review organization and
the patient is notified before the expiration of the initial 15-day period of
the circumstances requiring the extension of time and the date by which the
utilization review organization expects to render a determination. If the patient fails to submit the
information necessary to decide the case, the notice of extension shall
specifically describe the required information, and the patient shall be given
at least 45 days from the receipt of notice to respond to the plan’s request
for information. This time limit shall
be computed as required in K.S.A. 60-206(a) and amendments thereto.
(4) Each
utilization review organization shall issue a determination for retrospective
review within 30 days of the request for a utilization management
determination. This period may be
extended once by the utilization review organization for up to 15 days if the
extension is necessary due to matters beyond the control of the utilization
review organization and the patient is notified before the expiration of the
initial 15-day period of the circumstances requiring the extension of time and
the date by which the utilization review organization expects to render a
determination. If the patient fails to
submit the information necessary to decide the case, the notice of extension
shall specifically describe the required information, and the patient shall be
given at least 45 days from the receipt of notice to respond to the plan’s
request for information. This time limit
shall be computed as required in K.S.A. 60-206(a) and amendments thereto.
(5) For
each concurrent review, the utilization review organization shall adhere to the
following time frames, which shall be computed as required in K.S.A. 60-206(a)
and amendments thereto:
(A) For
reductions or terminations in a previously approved course of treatment, determinations
are issued far enough in advance of the reduction or termination to allow for
an appeal of the determination to be completed; and
(B) for
requests to extend a current course of treatment, determinations are issued
according to either of the following time frames:
(i) Within 24 hours of the request for a utilization
management determination, if it is a case involving urgent care and the request
for extension was received at least 24 hours before the expiration of the
currently certified period or treatments; or
(ii) within
72 hours of the request for a utilization management determination, if it is a
case involving urgent care and the request for extension was received less than
24 hours, excluding intermediate Saturdays, Sundays, and legal holidays, before
the expiration of the currently certified period or treatments.
(b)
Each utilization review
organization shall maintain written procedures for providing notification of
determinations regarding all forms of certification in accordance with the
following:
(1)
When an initial determination
is made to certify, the utilization review organization shall notify the
attending health care provider or other ordering provider, facility rendering
service, and enrollee or patient promptly in writing, by telephone, or by
electronic transmission.
(2)
The utilization review
organization shall transmit each determination to certify an extended stay or
additional services resulting from a concurrent review to the attending health
care provider or other ordering provider and the facility rendering services by
telephone, by electronic transmission, or in writing. The determination shall
be transmitted within one working day of receipt of all information necessary
to complete the review process, but not later than the end of a current
certified period.
(3)
If a utilization review
organization transmits written confirmation of certification for continued
hospitalization or services, that notification shall include, when possible,
the number of extended days or the next review date, the new total number of
days or services approved, and the date of admission or onset of services.
(4)
When a prospective or concurrent review
determination is made not to certify an admission or extension of an inpatient
stay, course of treatment, or other service requiring a review determination,
the decision shall be made by a peer clinical reviewer only after not less
than at least two bona fide attempts have been made to contact and
consult with the attending health care provider.
(A)
If the attending health care provider
cannot be contacted in a timely manner, the utilization review organization
shall send written notification to the attending health care provider or
ordering provider and the enrollee or patient within one working day following
the determination. Each notification shall be accompanied by the most
appropriate telephone number necessary to facilitate an expedited appeal.
(i)
The utilization review
organization shall provide within one business day of receipt of the request
the opportunity for the attending health care provider or other ordering
provider to discuss the noncertification decision with a clinical peer
reviewer, if the original peer reviewer cannot be available within one business
day.
(ii)
If a reconsideration or
peer-to-peer conversation does not resolve a difference of opinion, the
utilization review organization shall, at the time of the conversation, inform
the attending health care provider or other ordering provider of the right to
initiate an expedited appeal or standard appeal and the procedure to do so.
(B)
The written notification shall
include the principal reasons for the determination and procedures to initiate
an appeal of the determination. A determination not to certify may be based on
a lack of adequate information to certify after a reasonable attempt has been
made to contact the health care provider.
(C)
Each of the letters to the provider, other
ordering provider, patient, and facility shall include tracking
information including a reference number and a statement that the clinical
rationale used in making the noncertification decision shall be provided in
writing upon request.
(D)
Upon request, the utilization review
organization shall provide the clinical rationale in writing to the provider,
patient, or facility rendering service.
(5)
When a retrospective
determination is made not to certify an admission, stay, or other service, the
decision shall be made only by a peer clinical reviewer. The utilization review
organization shall provide written notification of the determination to the
attending health care provider or other ordering provider, patient, and
hospital or facility rendering services. The written notification shall include
the principal reasons for the determination and the procedures to
initiate a standard appeal of the determination. The notification shall include
a statement that the clinical rationale used in making the determination will
be provided in writing upon request. A determination not to certify may be
based on a lack of adequate information to certify after a reasonable attempt
has been made to contact the health care provider.
(c) Each utilization review organization shall
maintain written procedures to address the failure or inability of a health
care provider, patient, or other representative to provide the necessary
information for review. If the patient or provider will not release the
necessary, clinically relevant information to the utilization review
organization, the utilization review organization may administratively deny
certification in accordance with its own policy or that of the health benefit
plan. (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 May 16, 1997; amended June 22, 2001; amended P-__________________.)