Session of 1999
By Committee on Financial Institutions and Insurance

  9             AN  ACT relating to accident and health insurance; concerning an exter-
10             nal review process; providing certain requirements.
12       Be it enacted by the Legislature of the State of Kansas:
13             Section  1. (a) For purposes of this section:
14             (1) "Adverse decision" means a utilization review determination by a
15       third-party administrator, an insurer, or a health care provider acting on
16       behalf of an insured that a proposed or delivered health care service which
17       would otherwise be covered under an insured's contract is not or was not
18       medically necessary or the health care treatment has been determined to
19       be experimental or investigational.
20             (2) "Health insurance plan" means any hospital or medical expense
21       policy, health, hospital or medical service corporation contract, and a plan
22       provided by a municipal group-funded pool, or a health maintenance
23       organization contract offered by an employer or any certificate issued
24       under any such policies, contracts or plans. Health insurance plan does
25       not include policies or certificates covering only accident, credit, dental,
26       disability income, long-term care, hospital indemnity, medicare supple-
27       ment, vision care, coverage issued as a supplement to liability insurance,
28       insurance arising out of a workers compensation or similar law, automo-
29       bile medical-payment insurance, or insurance under which benefits are
30       payable with or without regard to fault and which is statutorily required
31       to be contained in any liability insurance policy or equivalent self-
32       insurance.
33             (3) "Insured" means the beneficiary of any insurance company, fra-
34       ternal benefit society, health maintenance organization and nonprofit hos-
35       pital and medical service corporation authorized to transact health insur-
36       ance business in this state.
37             (b) The right to review under this section shall not be construed to
38       change the terms of coverage under a health insurance plan.
39             (c) The insurer shall provide written notice to the insured of a final
40       adverse decision and the opportunity and time period for requesting the
41       commissioner's review.
42             (d) An insured who has exhausted all available internal review pro-
43       cedures provided by the health insurance plan or has not received a final
44       decision from the insured within 90 days shall have the right to an in-
45       dependent external review of an adverse decision under a health insur-
46       ance plan. The independent review shall be available when the affected
47       person, provider acting on behalf of the insured or legally authorized
48       designee of the insured files a written request with the commissioner of
49       insurance within 60 days from receiving a final written determination
50       from the insured's health insurance plan.
51             (e) An insured shall provide all information required by the commis-
52       sioner to make a preliminary determination including the appeal form, a
53       copy of the final decision of denial and a fully executed release to obtain
54       any necessary medical records from the insurer and any other relevant
55       provider.
56             (f) In responding to the commissioner, the insurer shall provide a
57       complete explanation as to the basis of the decision adverse to the insured.
58             (g) Pursuant to a contract negotiated with the insurance department,
59       an independent reviewer organization shall conduct an external review of
60       the adverse decision under a health insurance plan.
61             (1) The reviewer organization shall include health care providers cre-
62       dentialed with respect to the health care service under review and who
63       have no conflict of interest relating to the performance of their duties
64       under this section.
65             (2) The reviews shall be done in accordance with standards of deci-
66       sion-making based on objective clinical evidence and shall resolve all is-
67       sues in a timely manner and provide expedited resolution when the de-
68       cision relates to emergency or urgent health care services.
69             (h) The commissioner of insurance shall:
70             (1) Notify the insured or health care provider in writing as to whether
71       the complaint will be sent for an external review;
72             (2) allow an insurer, an insured, a health care provider filing a com-
73       plaint on behalf of an insured or a legally authorized designee of the
74       insured to provide additional written information as may be relevant for
75       the commissioner to make a final decision on the complaint;
76             (3) make a decision on a complaint within 30 days after receiving all
77       necessary information; and
78             (4) design an expedited procedure for use in an emergency case for
79       purposes of rendering a decision.
80             (i) The decision of the independent reviewer organization shall be
81       binding on the health insurance plan and the insured.
82             (j) The commissioner of insurance is hereby authorized to negotiate
83       and enter into contracts necessary to perform the duties required by this
84       section.
85             (k) The commissioner of insurance shall adopt rules and regulations
86       necessary to carry out the purposes of this section. The rules and regu-
87       lations shall ensure that the commissioner of insurance is able to provide
88       an effective and efficient external review of health care services.
89        Sec.  2. This act shall take effect and be in force from and after its
90       publication in the statute book.