40-22a13.External review of adverse health caredecisions; definitions.On and after January 1, 2000, for the purposes of K.S.A. 40-22a13through 40-22a16 and amendments thereto:
(a) "Adverse decision" means a utilization review determination by athird-party administrator, a health insurance plan, an insurer or a healthcare provider acting on behalf of an insured that a proposed or deliveredhealth care service which would otherwise be covered under an insured'scontract is not or was not medically necessary or the health care treatment hasbeen determined to be experimental or investigational and, (1) if the requestedservice is provided in a manner that leaves the insured with a financialobligation to the provider or providers of such services, or (2) the adversedecision is the reason for the insured not receiving the requested services.
(b) "Emergency medical condition" means the sudden, and at the time,unexpected onset of a health condition that requires immediate medicalattention, where failure to provide medical attention would result in a seriousimpairment to bodily functions, serious dysfunction of a bodily organ orpart or would place a person's health in serious jeopardy.
(c) "External review organization" means an entity that conducts independentexternal reviews of adverse decisions pursuant to a contract with thecommissioner. Such entity shall have experience serving as the external qualityreview organization in health programs administered by the state of Kansas, orbe a nationally accredited external review organization which utilizes healthcare providers actively engaged in the practice of their profession in thestate of Kansas who are qualified and credentialed with respect to the healthcare service review. In the event no Kansas providers are qualified andcredentialed with respect to the review of any case, the external revieworganization shall have the discretion to employ health care providers whoactively engage in such health care provider's practice outside the state ofKansas.
(d) "Health insurance plan" means any hospital or medical expense policy,health, hospital or medical service corporation contract, and a plan providedby a municipal group-funded pool, or a health maintenance organization contractoffered by an employer or any certificate issued under any such policies,contracts or plans.
(e) "Insured" means the beneficiary of any health insurance company,fraternal benefit society, health maintenance organization, nonprofit hospitaland medical service corporation, municipal group funded pool, and theself-funded coverage established by the state of Kansas, or any hospital ormedical expense, health, hospital or medical service corporation contract or aplan provided by a municipal group-funded pool.
(f) "Insurer" means any health insurance company, fraternal benefit society,health maintenance organization, nonprofit hospital and medical servicecorporation, provider sponsored organizations, municipal group-funded pool andthe self-funded coverage established by the state of Kansas for its employees.
40-22a13.External review of adverse health caredecisions; definitions.On and after January 1, 2000, for the purposes of K.S.A. 40-22a13through 40-22a16 and amendments thereto:
(a) "Adverse decision" means a utilization review determination by athird-party administrator, a health insurance plan, an insurer or a healthcare provider acting on behalf of an insured that a proposed or deliveredhealth care service which would otherwise be covered under an insured'scontract is not or was not medically necessary or the health care treatment hasbeen determined to be experimental or investigational and, (1) if the requestedservice is provided in a manner that leaves the insured with a financialobligation to the provider or providers of such services, or (2) the adversedecision is the reason for the insured not receiving the requested services.
(b) "Emergency medical condition" means the sudden, and at the time,unexpected onset of a health condition that requires immediate medicalattention, where failure to provide medical attention would result in a seriousimpairment to bodily functions, serious dysfunction of a bodily organ orpart or would place a person's health in serious jeopardy.
(c) "External review organization" means an entity that conducts independentexternal reviews of adverse decisions pursuant to a contract with thecommissioner. Such entity shall have experience serving as the external qualityreview organization in health programs administered by the state of Kansas, orbe a nationally accredited external review organization which utilizes healthcare providers actively engaged in the practice of their profession in thestate of Kansas who are qualified and credentialed with respect to the healthcare service review. In the event no Kansas providers are qualified andcredentialed with respect to the review of any case, the external revieworganization shall have the discretion to employ health care providers whoactively engage in such health care provider's practice outside the state ofKansas.
(d) "Health insurance plan" means any hospital or medical expense policy,health, hospital or medical service corporation contract, and a plan providedby a municipal group-funded pool, or a health maintenance organization contractoffered by an employer or any certificate issued under any such policies,contracts or plans.
(e) "Insured" means the beneficiary of any health insurance company,fraternal benefit society, health maintenance organization, nonprofit hospitaland medical service corporation, municipal group funded pool, and theself-funded coverage established by the state of Kansas, or any hospital ormedical expense, health, hospital or medical service corporation contract or aplan provided by a municipal group-funded pool.
(f) "Insurer" means any health insurance company, fraternal benefit society,health maintenance organization, nonprofit hospital and medical servicecorporation, provider sponsored organizations, municipal group-funded pool andthe self-funded coverage established by the state of Kansas for its employees.
40-22a13.External review of adverse health caredecisions; definitions.On and after January 1, 2000, for the purposes of K.S.A. 40-22a13through 40-22a16 and amendments thereto:
(a) "Adverse decision" means a utilization review determination by athird-party administrator, a health insurance plan, an insurer or a healthcare provider acting on behalf of an insured that a proposed or deliveredhealth care service which would otherwise be covered under an insured'scontract is not or was not medically necessary or the health care treatment hasbeen determined to be experimental or investigational and, (1) if the requestedservice is provided in a manner that leaves the insured with a financialobligation to the provider or providers of such services, or (2) the adversedecision is the reason for the insured not receiving the requested services.
(b) "Emergency medical condition" means the sudden, and at the time,unexpected onset of a health condition that requires immediate medicalattention, where failure to provide medical attention would result in a seriousimpairment to bodily functions, serious dysfunction of a bodily organ orpart or would place a person's health in serious jeopardy.
(c) "External review organization" means an entity that conducts independentexternal reviews of adverse decisions pursuant to a contract with thecommissioner. Such entity shall have experience serving as the external qualityreview organization in health programs administered by the state of Kansas, orbe a nationally accredited external review organization which utilizes healthcare providers actively engaged in the practice of their profession in thestate of Kansas who are qualified and credentialed with respect to the healthcare service review. In the event no Kansas providers are qualified andcredentialed with respect to the review of any case, the external revieworganization shall have the discretion to employ health care providers whoactively engage in such health care provider's practice outside the state ofKansas.
(d) "Health insurance plan" means any hospital or medical expense policy,health, hospital or medical service corporation contract, and a plan providedby a municipal group-funded pool, or a health maintenance organization contractoffered by an employer or any certificate issued under any such policies,contracts or plans.
(e) "Insured" means the beneficiary of any health insurance company,fraternal benefit society, health maintenance organization, nonprofit hospitaland medical service corporation, municipal group funded pool, and theself-funded coverage established by the state of Kansas, or any hospital ormedical expense, health, hospital or medical service corporation contract or aplan provided by a municipal group-funded pool.
(f) "Insurer" means any health insurance company, fraternal benefit society,health maintenance organization, nonprofit hospital and medical servicecorporation, provider sponsored organizations, municipal group-funded pool andthe self-funded coverage established by the state of Kansas for its employees.
