40-22a09a.Same; internal review procedure.(a) Every health insurance plan for which utilization reviewis performed shallinclude a description of the health insurance plan's procedures for an insuredto obtain an internalappeal or review of an adverse decision. This description shall include allapplicable time periods,contact information, rights of the insured and available levels of appeal. Ifthe health insurer usesa utilization review organization, the insured shall be notified of the name ofsuch utilization revieworganization. The health insurance plan shall provide an insured with writtenor electronicnotification of any adverse decision, and a description of the health insuranceplan's internal appealor review procedure, including the insured's right to external review asprovided in K.S.A. 40-22a14and amendments thereto.The health insurance plan also shall notify the insured of the insured's rightto waive the second appeal or internal review and proceed directly to theexternal review as provided in K.S.A. 40-22a14 and amendments thereto.
(b) If the health insurance plan contains a provision for two levels ofinternal appeal or review of ahealth care decision which is adverse to the insured, the health insurance planshall allow the insuredto voluntarily waive such insured's right to the second internal appeal orreview. Such waiver shallbe made in writing to the health insurance plan and shall constitute theexhaustion of all availableinternal appeal or review procedures within the meaning of subsection (d) ofK.S.A. 40-22a14 andamendments thereto.
(c) If an insured elects to request the second internal appeal or review of ahealth care decision whichis adverse to the insured, the insured shall have the right to appear in personbefore a designatedrepresentative or representatives of the health insurance plan or utilizationreview organization at thesecond internal appeal or review meeting. If a majority of the designatedrepresentatives of thehealth plan or utilization review organization who will be deciding the secondinternal appeal orreview cannot be present in person, by telephone or by other electronic means,at least one of thosedesignated representatives who will be deciding the second internal appeal orreview shall be aphysician and shall be present in person, by telephone or by other electronicmeans. No physicianor other health care provider serving as a reviewer in an internal appeal orreview of an adversedecision shall be liable in damages to the insured or the health insurance planfor any opinionrendered as part of the internal appeal or review.
(d) All second internal appeals or reviews shall provide that the insured hasa right to:
(1) Receive from the health insurance plan or utilization revieworganization, upon request, copiesof all documents, records and other information that are not confidential orprivileged relevant to theinsured's request for benefits;
(2) have a reasonable and adequate amount of time to present the insured'scase to a designated representative or representatives of the health insuranceplan or utilization review organizationwhowill be deciding the second internal appeal or review;
(3) submit written comments, documents, records and other material relatingto the request forbenefits for the second internal appeal or review panel to consider whenconducting the secondinternal appeal or review both before and, if applicable, at the secondinternal appeal or reviewmeeting;
(4) prior to or during the second internal appeal or review meeting askquestionsrelevant to the subject matterof the internal appeal or review of any representative of the health insuranceplan or utilizationreview organization serving on the internal appeal or review panel providedthat such representativemay respond verbally if the question is asked in person during an insured'sappearance before theinternal appeal or review panel or in writing if the questions are asked inwriting, not more than 30days from receipt of such written questions;
(5) be assisted or represented at the second internal appeal or reviewmeeting by an individual orindividuals of the insured's choice; and
(6) record the proceedings of the second internal appeal or review meeting atthe expense of theinsured.
(e) An insured, or the insured's authorized representative, wishing torequest to appear in personbefore the second internal appeal or review panel consisting of the healthinsurance plan's orutilization review organization's designated representative or representativesshall make the requestto the health insurance plan or utilization review organization within fiveworking days before thedate of the scheduled review meeting except that in the case of an emergencymedical condition, suchrequest must be made no less than 24 hours prior to the scheduled reviewmeeting.
(f) The health insurance plan or utilization review organization shallprovide the insured a writtendecision setting forth the relevant facts and conclusions supporting itsdecision within:
(1) Seventy-two hours if the second internal appeal or review involves anemergencymedicalcondition as definedby subsection (b) of K.S.A. 40-22a13 and amendments thereto;
(2) fifteen business days if the second internal appeal or review involves apre-serviceclaim; and
(3) thirty days if the second internal appeal or review involves apost-serviceclaim.
(g) For the purposes of this section:
(1) "Health insurance plan" shall have the meaning ascribed to it in K.S.A.40-22a13 andamendments thereto.
(2) "Insured" shall have the meaning ascribed to it in K.S.A. 40-22a13 andamendments thereto.
(3) "Insurer" shall have the meaning ascribed to it in K.S.A. 40-22a13 andamendments thereto.
(4) "Adverse decision" shall have the meaning ascribed to it in K.S.A.40-22a13 and amendmentsthereto.
(5) "Pre-service claim" means a request for a claims decision when priorauthorization of servicesis required.
(6) "Post-service claim" means a request for a claims decision for servicesthat have already beenprovided.
(h) This section shall be a part of and supplemental to the utilizationreview act.
40-22a09a.Same; internal review procedure.(a) Every health insurance plan for which utilization reviewis performed shallinclude a description of the health insurance plan's procedures for an insuredto obtain an internalappeal or review of an adverse decision. This description shall include allapplicable time periods,contact information, rights of the insured and available levels of appeal. Ifthe health insurer usesa utilization review organization, the insured shall be notified of the name ofsuch utilization revieworganization. The health insurance plan shall provide an insured with writtenor electronicnotification of any adverse decision, and a description of the health insuranceplan's internal appealor review procedure, including the insured's right to external review asprovided in K.S.A. 40-22a14and amendments thereto.The health insurance plan also shall notify the insured of the insured's rightto waive the second appeal or internal review and proceed directly to theexternal review as provided in K.S.A. 40-22a14 and amendments thereto.
(b) If the health insurance plan contains a provision for two levels ofinternal appeal or review of ahealth care decision which is adverse to the insured, the health insurance planshall allow the insuredto voluntarily waive such insured's right to the second internal appeal orreview. Such waiver shallbe made in writing to the health insurance plan and shall constitute theexhaustion of all availableinternal appeal or review procedures within the meaning of subsection (d) ofK.S.A. 40-22a14 andamendments thereto.
(c) If an insured elects to request the second internal appeal or review of ahealth care decision whichis adverse to the insured, the insured shall have the right to appear in personbefore a designatedrepresentative or representatives of the health insurance plan or utilizationreview organization at thesecond internal appeal or review meeting. If a majority of the designatedrepresentatives of thehealth plan or utilization review organization who will be deciding the secondinternal appeal orreview cannot be present in person, by telephone or by other electronic means,at least one of thosedesignated representatives who will be deciding the second internal appeal orreview shall be aphysician and shall be present in person, by telephone or by other electronicmeans. No physicianor other health care provider serving as a reviewer in an internal appeal orreview of an adversedecision shall be liable in damages to the insured or the health insurance planfor any opinionrendered as part of the internal appeal or review.
(d) All second internal appeals or reviews shall provide that the insured hasa right to:
(1) Receive from the health insurance plan or utilization revieworganization, upon request, copiesof all documents, records and other information that are not confidential orprivileged relevant to theinsured's request for benefits;
(2) have a reasonable and adequate amount of time to present the insured'scase to a designated representative or representatives of the health insuranceplan or utilization review organizationwhowill be deciding the second internal appeal or review;
(3) submit written comments, documents, records and other material relatingto the request forbenefits for the second internal appeal or review panel to consider whenconducting the secondinternal appeal or review both before and, if applicable, at the secondinternal appeal or reviewmeeting;
(4) prior to or during the second internal appeal or review meeting askquestionsrelevant to the subject matterof the internal appeal or review of any representative of the health insuranceplan or utilizationreview organization serving on the internal appeal or review panel providedthat such representativemay respond verbally if the question is asked in person during an insured'sappearance before theinternal appeal or review panel or in writing if the questions are asked inwriting, not more than 30days from receipt of such written questions;
(5) be assisted or represented at the second internal appeal or reviewmeeting by an individual orindividuals of the insured's choice; and
(6) record the proceedings of the second internal appeal or review meeting atthe expense of theinsured.
(e) An insured, or the insured's authorized representative, wishing torequest to appear in personbefore the second internal appeal or review panel consisting of the healthinsurance plan's orutilization review organization's designated representative or representativesshall make the requestto the health insurance plan or utilization review organization within fiveworking days before thedate of the scheduled review meeting except that in the case of an emergencymedical condition, suchrequest must be made no less than 24 hours prior to the scheduled reviewmeeting.
(f) The health insurance plan or utilization review organization shallprovide the insured a writtendecision setting forth the relevant facts and conclusions supporting itsdecision within:
(1) Seventy-two hours if the second internal appeal or review involves anemergencymedicalcondition as definedby subsection (b) of K.S.A. 40-22a13 and amendments thereto;
(2) fifteen business days if the second internal appeal or review involves apre-serviceclaim; and
(3) thirty days if the second internal appeal or review involves apost-serviceclaim.
(g) For the purposes of this section:
(1) "Health insurance plan" shall have the meaning ascribed to it in K.S.A.40-22a13 andamendments thereto.
(2) "Insured" shall have the meaning ascribed to it in K.S.A. 40-22a13 andamendments thereto.
(3) "Insurer" shall have the meaning ascribed to it in K.S.A. 40-22a13 andamendments thereto.
(4) "Adverse decision" shall have the meaning ascribed to it in K.S.A.40-22a13 and amendmentsthereto.
(5) "Pre-service claim" means a request for a claims decision when priorauthorization of servicesis required.
(6) "Post-service claim" means a request for a claims decision for servicesthat have already beenprovided.
(h) This section shall be a part of and supplemental to the utilizationreview act.
40-22a09a.Same; internal review procedure.(a) Every health insurance plan for which utilization reviewis performed shallinclude a description of the health insurance plan's procedures for an insuredto obtain an internalappeal or review of an adverse decision. This description shall include allapplicable time periods,contact information, rights of the insured and available levels of appeal. Ifthe health insurer usesa utilization review organization, the insured shall be notified of the name ofsuch utilization revieworganization. The health insurance plan shall provide an insured with writtenor electronicnotification of any adverse decision, and a description of the health insuranceplan's internal appealor review procedure, including the insured's right to external review asprovided in K.S.A. 40-22a14and amendments thereto.The health insurance plan also shall notify the insured of the insured's rightto waive the second appeal or internal review and proceed directly to theexternal review as provided in K.S.A. 40-22a14 and amendments thereto.
(b) If the health insurance plan contains a provision for two levels ofinternal appeal or review of ahealth care decision which is adverse to the insured, the health insurance planshall allow the insuredto voluntarily waive such insured's right to the second internal appeal orreview. Such waiver shallbe made in writing to the health insurance plan and shall constitute theexhaustion of all availableinternal appeal or review procedures within the meaning of subsection (d) ofK.S.A. 40-22a14 andamendments thereto.
(c) If an insured elects to request the second internal appeal or review of ahealth care decision whichis adverse to the insured, the insured shall have the right to appear in personbefore a designatedrepresentative or representatives of the health insurance plan or utilizationreview organization at thesecond internal appeal or review meeting. If a majority of the designatedrepresentatives of thehealth plan or utilization review organization who will be deciding the secondinternal appeal orreview cannot be present in person, by telephone or by other electronic means,at least one of thosedesignated representatives who will be deciding the second internal appeal orreview shall be aphysician and shall be present in person, by telephone or by other electronicmeans. No physicianor other health care provider serving as a reviewer in an internal appeal orreview of an adversedecision shall be liable in damages to the insured or the health insurance planfor any opinionrendered as part of the internal appeal or review.
(d) All second internal appeals or reviews shall provide that the insured hasa right to:
(1) Receive from the health insurance plan or utilization revieworganization, upon request, copiesof all documents, records and other information that are not confidential orprivileged relevant to theinsured's request for benefits;
(2) have a reasonable and adequate amount of time to present the insured'scase to a designated representative or representatives of the health insuranceplan or utilization review organizationwhowill be deciding the second internal appeal or review;
(3) submit written comments, documents, records and other material relatingto the request forbenefits for the second internal appeal or review panel to consider whenconducting the secondinternal appeal or review both before and, if applicable, at the secondinternal appeal or reviewmeeting;
(4) prior to or during the second internal appeal or review meeting askquestionsrelevant to the subject matterof the internal appeal or review of any representative of the health insuranceplan or utilizationreview organization serving on the internal appeal or review panel providedthat such representativemay respond verbally if the question is asked in person during an insured'sappearance before theinternal appeal or review panel or in writing if the questions are asked inwriting, not more than 30days from receipt of such written questions;
(5) be assisted or represented at the second internal appeal or reviewmeeting by an individual orindividuals of the insured's choice; and
(6) record the proceedings of the second internal appeal or review meeting atthe expense of theinsured.
(e) An insured, or the insured's authorized representative, wishing torequest to appear in personbefore the second internal appeal or review panel consisting of the healthinsurance plan's orutilization review organization's designated representative or representativesshall make the requestto the health insurance plan or utilization review organization within fiveworking days before thedate of the scheduled review meeting except that in the case of an emergencymedical condition, suchrequest must be made no less than 24 hours prior to the scheduled reviewmeeting.
(f) The health insurance plan or utilization review organization shallprovide the insured a writtendecision setting forth the relevant facts and conclusions supporting itsdecision within:
(1) Seventy-two hours if the second internal appeal or review involves anemergencymedicalcondition as definedby subsection (b) of K.S.A. 40-22a13 and amendments thereto;
(2) fifteen business days if the second internal appeal or review involves apre-serviceclaim; and
(3) thirty days if the second internal appeal or review involves apost-serviceclaim.
(g) For the purposes of this section:
(1) "Health insurance plan" shall have the meaning ascribed to it in K.S.A.40-22a13 andamendments thereto.
(2) "Insured" shall have the meaning ascribed to it in K.S.A. 40-22a13 andamendments thereto.
(3) "Insurer" shall have the meaning ascribed to it in K.S.A. 40-22a13 andamendments thereto.
(4) "Adverse decision" shall have the meaning ascribed to it in K.S.A.40-22a13 and amendmentsthereto.
(5) "Pre-service claim" means a request for a claims decision when priorauthorization of servicesis required.
(6) "Post-service claim" means a request for a claims decision for servicesthat have already beenprovided.
(h) This section shall be a part of and supplemental to the utilizationreview act.
