KANSAS INSURANCE
DEPARTMENT
K.A.R. 40-4-41e. Utilization review
organizations; staff requirements. Each utilization review
organization shall have utilization review staff who are properly trained,
qualified, supervised, and supported by written, clinically substantiated
criteria and review procedures. (a)(1) For data collection, intake screening,
and scripted clinical screening, the use of nonclinical administrative staff
shall be limited to the following:
(A)
The performance of “review of
service requirements requests” for completeness;
(B)
the collection and transfer of
nonclinical data;
(C)
the acquisition of structured
clinical data; and
(D)
any scripted clinical screening
that does not require evaluation or interpretation of clinical information.
(2) Nonclinical
administrative staff performing the functions listed in paragraph paragraphs
(a)(1)(A) through (D) shall meet the following conditions:
(A)
Be qualified and trained to
perform “review of service requests”;
(B)
be supported by explicit
instructions and scripts;
(C) be trained in the principles and procedures of
the collection and transfer of nonclinical data, the acquisition of structured
clinical data, scripted clinical screening, and the maintenance of
confidentiality of patient-specific information;
(D)
through an established process, promptly
transfer a telephone call for review of services to an initial clinical
reviewer if the review cannot be completed based on a formal script; and
(E)
be monitored by a licensed health professional
while performing an administrative review.
(b) The
utilization review organization, when conducting an initial clinical
review, shall perform the following:
(1)
Refer review of services that
do not meet initial review criteria to peer clinical review;
(2)
restrict the performance of the initial
clinical review to individuals who meet both of the following requirements:
(A)
Are health professionals; and
(B)
possess a current and valid
professional license or certificate in the state or states in which they work.
If the state in which they work does not require professional licensure, each
of the individuals shall possess a current and valid professional license or
certificate in another state or shall be certified by the national accrediting
body appropriate to each individual's profession;
(3)
require initial clinical
reviewers to be trained in the principles and procedures of utilization review;
and
(4)
require initial clinical
reviewers to be supported by a doctor of osteopathic medicine or a clinical
director who has an unrestricted license to practice medicine.
(c)(1) The utilization review organization shall
conduct peer clinical reviews for all cases in which a clinical determination
to certify cannot be made by initial clinical review. Peer clinical reviews
shall be conducted by health professionals who meet the following criteria:
(A)
Directly support the
utilization review activity;
(B)
are oriented in the principles
and procedures of utilization management and peer review;
(C)
are qualified to render a clinical opinion
about the medical condition, procedures, and treatment under review; and
(D)
meet one of the following
criteria:
(i)
Hold a current, unrestricted
license in the same licensure category as that of the attending health care
provider or other ordering provider; or
(ii)
for standard appeals, are in
active practice.
(2) The
utilization review organization shall have a medical director or clinical
director with professional postresidency experience in direct patient care who
meets one of the following criteria:
(A)
Holds an unrestricted license
to practice medicine; or
(B)
has a clinical specialty
appropriate to the type of single service utilization management conducted.
(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-__________________.)