40-22a15. Same; insurance commissioner's powers and duties; external review organizations, decisions, immunity from liability.
40-22a15
40-22a15. Same; insurance commissioner's powers andduties; external review organizations, decisions, immunity fromliability.On and after January 1, 2000:
(a) The commissioner shall:
(1) Negotiate contracts with external review organizations which areeligible to conduct independent review of the adverse decision by a healthinsurance plan or insurer;
(2) allow the insurer or the health insurance plan, an insured or treatingphysician or health care provider acting on behalf of the insured, or legallyauthorized designee filing a request for external review to provide additionalwritten information as may be relevant for the commissioner to make a finaldecision on whether the request qualified for external review;
(3) make a decision on a request for external review within 10 business daysafter receiving all necessary information;
(4) notify the insured and treating physician or health care provider actingon behalf of the insured, or legally authorized designee, and insurer or healthinsurance plan in writing that a request for external review will or will notbe granted; and
(5) design and implement an expedited procedure for use in an emergencymedical condition for purposes of the external review organization rendering adecision.
(b) The external review organization as defined in subsection (c) of K.S.A.40-22a13, and amendments thereto, shall provide that all reviewscompleted pursuant toK.S.A. 40-22a13 through 40-22a16, and amendments thereto, areconducted by qualified andcredentialed health careproviders with respect to the healthcare service under review and who have no conflict of interest relating to theperformance of the external review organization's duties in K.S.A.40-22a13 through 40-22a16, and amendments thereto.
(c) The external review organization shall issue a written decision to theinsured and concurrently send a copy of such decision to the commissionerincluding the basis and rationale for its decision within 30 business days.The standard of review shall be whether the health care service denied by theinsurer or health insurance plan was medically necessary under the terms of theinsured's contract. In reviews regarding experimental or investigationaltreatment, the standard of review shall be whether the health care servicedenied by the insurer or health insurance plan was covered or excluded fromcoverage under the terms of the insured's contract.
(d) The external review organization shall provide expedited resolution whenan emergency medical condition exists, and shall resolve all issues withinseven business days.
(e) The external review organization shall maintain and report such data asmay be required by the commissioner in order to assess the effectiveness of theexternal review process.
(f) No external review organization nor any individual working on behalf ofsuch organization shall be liable in damages to any insured, health insuranceplan or insurer for any opinion rendered as part of an external reviewconducted pursuant to K.S.A. 40-22a13 through 40-22a16, andamendments thereto.
(g) The external review organization shall maintain confidentiality of themedical records of the insured in accordance to state and federal law.
History: L. 1999, ch. 162, § 8; July 1.