KANSAS INSURANCE DEPARTMENT
K.A.R. 40-4-41f.
Utilization review organizations; review requirements. (a)
Each utilization review organization shall use written, clinically
substantiated criteria, as needed, for the purpose of determining or screening
the appropriateness of the certification.
(1)
This
The criteria shall be periodically evaluated and updated, and
shall be made available to the attending health care provider or other ordering
provider upon request.
(2)
Professionally accepted review
criteria shall be used for concurrent reviews and shall be periodically
evaluated and updated.
(3)
When
If copyright laws prohibit the copying of criteria for health care
providers, the utilization review organization shall identify the type of
criteria being utilized so that the health care provider may can
purchase the criteria directly from the source.
(4)
Clinical protocols, as well as
other relevant review processes used in a health benefit plan's concurrent
review program, shall be established with appropriate involvement from health
care provider panels made up consisting of health care providers
contracting with the utilization review organization.
(b) Each utilization review organization shall
use one or more health care provider consultants, including, as needed and
available, one or more specialists who are board-certified and working toward
certification in a specialty board approved by the American board of
medical specialists or the American board of osteopathy from the major areas of
clinical services.
(c) Each utilization review organization shall
use one or more peer clinical reviewers who meet the following criteria:
(1)
Have an a firm
understanding of clinical practice;
(2)
are familiar with current
treatment guidelines;
(3)
are able to access expert
clinical opinions when necessary; and
(4)
take into consideration any
local specific issues as described by the attending health care provider.
(d) Each
utilization review organization shall provide a formal program for orientation
and training of utilization review staff and professional consultants.
(e) Each
utilization review organization shall maintain written documentation of an
active quality management program that promotes objective and systematic
monitoring and evaluation of utilization review processes and services.
(f) The
Each utilization review organization shall, as part of its quality
management program, include a written plan addressing the following:
(1)
Scope and objectives;
(2)
program organization;
(3)
monitoring and oversight
mechanisms; and
(4)
evaluation and organizational
improvement of clinical review activities.
(g) The
Each utilization review organization shall, as part of its
(1)
Objectives and approaches
utilized in the monitoring and evaluation of clinical review activities,
including the systematic evaluation of complaints for patterns or trends;
(2)
the implementation of action
plans to improve or correct identified problems; and
(3)
the mechanisms to communicate
the results of the action plans to utilization review staff.
(h) Each utilization review organization shall have a
mechanism to ensure that the utilization management process, including the
decision making of staff and reviewers, is not influenced by conflicts of
interest. (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-__________________.)