KANSAS INSURANCE DEPARTMENT
K.A.R. 40-4-41d. Utilization review
organizations; appeal procedures. Each utilization review
organization shall have in place procedures for a formal process to
consider appeals of a determination not to certify an admission, procedure,
service, or extension of stay. The appeal process shall include the
availability of a standard appeal for nonurgent cases and an expedited appeal
for cases involving urgent care. The
right to appeal shall be available to the patient or enrollee, the
representative of the patient or enrollee, and the attending health care
provider, other ordering provider, or facility rendering service on behalf of
the patient. Hospitals or other health care providers may assist in an appeal.
The procedures for appeals shall include, at a minimum, the following: (a) Each utilization review organization
shall allow the patient, provider, or facility rendering services at least 180
days, excluding intermediate
Saturdays, Sundays, and legal holidays, after receipt of a
notice of noncertification to initiate the appeal process by telephone or
written notification.
(b) Each
utilization review organization shall provide the patient, provider, or
facility rendering the service with the opportunity to submit written comments,
documents, records, or other information relating to the case.
(c) Each utilization review organization and the individuals
considering the appeal shall take into account all documents, records, and
other information submitted by the patient, provider, or facility rendering
service relating to the case without regard to whether the information was
submitted or considered in the initial consideration of the case.
(d) Each utilization review organization
shall keep a record of each appeal that includes the names of the patient,
provider, and facility that rendered the service, copies of all correspondence
regarding the appeal, the dates of appeal reviews, documentation of actions
taken, final resolutions, and minutes or transcripts of appeal proceedings, if
any.
(e) Each utilization review organization
shall provide an expedited appeal process for cases involving urgent
care.
(1)
When
If an initial determination not to certify a health care service is made
before or during an ongoing service requiring review, and the attending
health care provider or other ordering provider believes that the determination
warrants immediate appeal, the attending health care provider or other ordering
provider shall have an opportunity to appeal that determination over the
telephone or via facsimile, on an expedited basis.
(2)
Each utilization review organization shall
provide reasonable access to a peer clinical reviewer, not to exceed
one working day, by telephone or in person to discuss the determination
with the attending health care provider or other ordering providers. The peer
clinical reviewer shall be available for these appeals during normal business
hours.
(3)
The peer clinical reviewer
shall have immediate access to the material that formed the basis for the
original determination when discussing an appeal.
(4)
The utilization review
organization shall not be required to provide a peer clinical reviewer other
than the peer clinical reviewer who made the original decision if the attending
health care provider or other ordering provider only needs to supply additional
or new information that will justify the need for the health care service or
treatment.
(5)
Health care providers and
utilization review organizations shall attempt to share the maximum amount of
information by telephone, facsimile, or other means to resolve the expedited
appeal satisfactorily.
(6)
The utilization review
organization shall notify the attending health care provider or the ordering
provider of its decision regarding the expedited appeal by telephone at the
time when the decision is made and shall notify either the attending
health care provider or other ordering provider and the enrollee in writing
within one working day.
(7)
Expedited appeals that do not
resolve a difference of opinion may be resubmitted through the standard appeal
process.
(8)
Noncertifications made on a
retrospective basis may be appealed only through the standard appeal process.
(9) Each expedited appeal shall be completed as soon as
possible, and no later than 72 hours after the initiation of the appeal process, excluding intermediate Saturdays, Sundays, and
legal holidays.
Completion of the appeal shall include the provision of written
notification of the appeal decision issued.
(10) The written notification of each adverse appeal determination
shall include the principal reasons for the determination, the clinical
rationale used in making the appeal decision, and information about additional
appeal mechanisms available, if any.
(b) (f) Standard
appeal. The Each utilization review organization shall
establish procedures for standard appeals to be made either in writing
or by telephone.
(1)
Each utilization review
organization shall notify in writing the enrollee or patient, attending health
care provider or other ordering provider, and claims administrator of its
determination on the appeal as soon as practical, but never later than 30 days,
in the absence of any contractual agreement, after receiving the required
documentation for the appeal after the initiation of the appeal process, excluding intermediate Saturdays, Sundays and legal
holidays.
(2)
The documentation required by
the utilization review organization may include copies of part or all of the
clinical record or a written statement from the attending health care provider
or other ordering provider.
(3)
Before upholding the original
decision not to certify for clinical reasons, a peer clinical reviewer who did
not make the original noncertification determination shall review the
documentation.
(4) The
process established by a utilization review organization may include a period
within which an appeal shall be filed to be considered. Written notification of each adverse
appeal determination shall be provided to each attending health care provider
or other ordering provider and shall include the principal reasons for the
determination and information about additional appeal mechanisms available, if
any.
(5) Each
attending health care provider or other ordering provider who unsuccessfully
appeals a determination not to certify shall be provided the clinical basis for
that determination in writing, upon request.
(6) In
cases involving physician-directed services in which an appeal to reverse a
determination not to certify for medical reasons is unsuccessful, the utilization
review organization shall assure ensure that a peer clinical
reviewer, in the same or a similar medical specialty as that of the attending
health care provider or other ordering provider, is reasonably available to
review the case as mutually deemed appropriate.
(7) In
cases involving other than physician-directed services in which an appeal to
reverse a determination not to certify for clinical reasons is unsuccessful,
the utilization review organization shall assure ensure that a
peer clinical reviewer, in the same or similar profession as that of the
attending health care provider or other ordering provider, is reasonably
available to review the case as mutually deemed appropriate.
(8) Each
utilization review organization shall forward, by written notification, a
certification or a determination not to certify to the enrollee or patient,
attending health care provider or other ordering provider, and claims
administrator for the health benefit plan.
(9) The
utilization review organization shall conduct appeals considerations by
requiring health professionals who serve as clinical peers and who consider
appeals to meet the following conditions:
(A)
Hold a current active,
unrestricted license to practice medicine or a health profession;
(B)
for services provided by a
physician, medical doctor, or doctor of osteopathic medicine, be
board-certified by either of the following:
(i)
A specialty board approved by
the American board of medical specialties, for doctors of medicine; or
(ii)
the advisory board of
osteopathic specialists from the major areas of clinical services, for doctors
of osteopathic medicine;
(C)
for services provided by a
nonmedical doctor or doctor of osteopathic medicine, be in the same profession
and in a similar specialty as that which typically manages the medical
condition, procedure, or treatment mutually deemed appropriate; and
(D) be
oriented to the principles and procedures of utilization review and peer review;
and
(E) be neither the individual who made the original
noncertification nor the subordinate of that individual. (Authorized by K.S.A. 40-103, 40-22a04, and
40-22a11; implementing K.S.A. 40-22a04 and 40-22a11; effective,
T-40-4-26-95, April 26, 1995; effective June 12, 1995; amended June 22, 2001; amended P-__________________.)