KANSAS INSURANCE DEPARTMENT
K.A.R. 40-4-41i. Utilization review
organizations; program qualifications. (a) The Each utilization review
organization shall utilize explicit clinical review criteria or scripts for
scripted clinical screening that meet the following criteria:
(1)
Are developed with involvement
from appropriate, actively practicing physicians and other providers with
current knowledge relevant to the criteria or scripts under review;
(2)
are based on sound clinical
principles and processes;
(3)
are evaluated at least annually
and are updated, if necessary; and
(4)
if used in a review that leads
to a noncertification decision for a specific case under review, are disclosed
to the physician, provider, and patient upon request; and
(5) are
approved by the medical director or clinical director.
(b) The
Each utilization review organization shall implement and document a
structured professional staff review program that demonstrates a formal program
of orientation and training for all clinical reviewers.
(c) The
Each utilization review organization shall establish written clinical
qualifications and a process for periodic performance evaluation for all
clinical reviewers, both staff and consultant.
This periodic performance evaluation shall include a review of the
case files of each member of the utilization management staff.
(d) The
Each utilization review organization shall conduct a periodic formal
program for training, as well as ongoing monitoring and evaluation of the
performance of nonclinical administrative staff involved in all levels of the
review process. (Authorized by K.S.A. 40-103, K.S.A. 1999 Supp. 40-22a04,
and 40-22a11; implementing K.S.A. 1999 Supp. 40-22a04, 40-22a06, 40-22a07,
and 40-22a11; effective June 22, 2001; amended P-__________________.)