"Application for Utilization Review Certificate" - Kansas

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APPLICATION
Kansas Utilization Review Organization Certificate
1. Legal Name of Applicant:
Mailing Address:
Contact Person:
Title:
Phone Number:
Fax Number:
E-Mail Address:
Toll Free Number:
2. Is the applicant accredited by and adhering to the health utilization management standards
approved by URAC? Select YES / NO. If so, please attach a copy of the current certificate of
accreditation to this application, answer question 7 on page two and complete the final page.
There is no fee if currently accredited by URAC. K.S.A. 40-22a04(b)(1) requires the signature of
the chief executive officer.
The following must be assembled in a binder, with consecutive cross-referenced tabs as
directed. A general UM program description alone is not sufficient. A USB jump drive may also
be provided as back-up of the submitted hard copies.
3. Provide a certified copy of the URO’s charter or articles of incorporation and bylaws, if any.
(Reference as item 3)
4. State the applicant's location of each office(s) where utilization review affecting residents or
health care providers of this state will be performed.
(Reference as item 4)
5. State the telephone number(s) facsimile number(s) and toll free number(s) used for
utilization review.
(Reference as item 5)
6. Please provide qualifications of individuals performing utilization review at the location(s)
identified in item 4. This summary should include a spreadsheet of all staff either employed by
or under contract to perform utilization review and include the qualifications (such as
specialties or subspecialties in which an individual is licensed or certified, and professional
affiliations such as M.D., D.O., D.C., R.N., etc.) of each staff member and State of licensure.
Please also include a column for the expiration/renewal date of their certification/licensure.
(Reference as item 6)
APPLICATION
Kansas Utilization Review Organization Certificate
1. Legal Name of Applicant:
Mailing Address:
Contact Person:
Title:
Phone Number:
Fax Number:
E-Mail Address:
Toll Free Number:
2. Is the applicant accredited by and adhering to the health utilization management standards
approved by URAC? Select YES / NO. If so, please attach a copy of the current certificate of
accreditation to this application, answer question 7 on page two and complete the final page.
There is no fee if currently accredited by URAC. K.S.A. 40-22a04(b)(1) requires the signature of
the chief executive officer.
The following must be assembled in a binder, with consecutive cross-referenced tabs as
directed. A general UM program description alone is not sufficient. A USB jump drive may also
be provided as back-up of the submitted hard copies.
3. Provide a certified copy of the URO’s charter or articles of incorporation and bylaws, if any.
(Reference as item 3)
4. State the applicant's location of each office(s) where utilization review affecting residents or
health care providers of this state will be performed.
(Reference as item 4)
5. State the telephone number(s) facsimile number(s) and toll free number(s) used for
utilization review.
(Reference as item 5)
6. Please provide qualifications of individuals performing utilization review at the location(s)
identified in item 4. This summary should include a spreadsheet of all staff either employed by
or under contract to perform utilization review and include the qualifications (such as
specialties or subspecialties in which an individual is licensed or certified, and professional
affiliations such as M.D., D.O., D.C., R.N., etc.) of each staff member and State of licensure.
Please also include a column for the expiration/renewal date of their certification/licensure.
(Reference as item 6)
7. Has the applicant, or any one of its incorporators, owners, partners, vendors, officers, or
staff performing utilization review, ever had an application to perform utilization review, or
similar license, or authority denied, revoked, or suspended, or been fined; or had any
professional, vocational, or business license denied, suspended or revoked by any public
authority in this or any other state? YES / NO. If yes, provide an explanation including amount
of fine(s) and summary judgement order identification reference.
(Reference as item 7)
8. intentionally blank
9. Identify the type(s) of reviews conducted by the applicant, such as:
prospective, concurrent, and retrospective review. Please also state if the scope of review is
limited, such as Dental only, Behavioral Health only, etc.
(Reference as item 9)
C
S
1
40
ORE
TANDARDS
THROUGH
10. Demonstrate compliance with each of the Core Standards as required by K.A.R. 40-4-41.
Please submit the applicant’s policies and procedures for each of the Core Standards 1 – 40.
NOTE: A general UM program description alone is not sufficient. Each core must be separated
by tabs as follows:
(Reference as Item 10)
Tab 1
Organizational structure
(include chart)
Cores 1 and 2
Tab 2
Policies and Procedures
(include master list)
Core 3
Tab 3
Regulatory Compliance
Core 4
Tab 4
Inter-Departmental Coordination
Core 5
Tab 5
Oversight of Delegation Functions
Cores 6, 7, 8, 9
Tab 6
Marketing and Sales Communications
Core 10
Tab 7
Business Relationships
Core 11 and 12
Tab 8
Information Management
Cores 13 through 16
Tab 9
Quality Management
Cores 17 through 24
Tab 10
Staff Qualifications
Cores 25 and 26
Tab 11
Staff Management
Cores 27, 28, 29
Tab 12
Clinical Staff Credentialing and Oversight
Cores 30 through 35
Tab 13
Consumer Protection & System Coordination
Core 36
Tab 14
Consumer Protection & Empowerment
Cores 37 through 40
H
U
M
S
1
41
EALTH
TILIZATION
ANAGEMENT
TANDARDS
THROUGH
Submit your written policies and procedures to demonstrate compliance with each of the
Health Utilization Management (HUM) Standards as required by K.A.R. 40-4-41. Each UM
standard must be separated by tab item number, and in the order as follows.
NOTE: A general Utilization Management program description alone is not sufficient.
11. Summarize the applicant’s review criteria requirements to demonstrate compliance with
UM1.
(Reference as Item 11)
12. Submit written procedures demonstrating accessibility of review services. This response
should include how the applicant complies with UM2, UM3, UM4.
(Reference as Item 12)
13. Demonstrate compliance with the onsite review services requirements stated within UM 5.
(Reference as Item 13)
14. Demonstrate compliance with initial screening requirements by submitting the policies and
procedures documents that govern the limitations in the use of non-clinical staff, Pre-review
screening staff oversight, and pre-review screening non-certifications as stated within
UM 7, UM 8 and, UM 9
(Reference as item 14)
15. Demonstrate compliance with the initial clinical review requirements by submitting the
policies and procedures documents that govern the initial reviewer qualifications, the initial
clinical reviewer resources and the initial clinical review non-certifications as required by
UM 10, UM 11, and UM 12.
(Reference as Item 15)
16. Demonstrate compliance with the Peer clinical review requirements by submitting the
policies and procedures documents that govern peer clinical review cases, peer clinical reviewer
qualifications, Drug UM reviewer qualifications, and prospective, concurrent and retrospective
drug UM as stated within UM 13, UM 14, UM15, and UM 16
(Reference as Item 16)
17. Demonstrate compliance with the peer to peer conversations requirements by providing
documents to support peer to peer conversation ability and also the alternative procedures
consistent with UM 17 and UM 18.
(Reference as Item 17)
18. Demonstrate compliance with timeframes for initial UM decisions as described in the
prospective, retrospective, and concurrent time frame sections of UM 19, UM 20 and UM 21.
(Reference as Item 18)
19. Demonstrate compliance with the notice of certification decisions requirements as
described within the certification decision notice and tracking section and the continued
certification decision requirements within UM 22 and UM 23.
(Reference as Item 19)
20. Demonstrate compliance with the notice of non-certification decisions requirements
regarding written notice of non-certifications and rationale and the clinical rationale for non-
certifications as stated with UM 24 and UM 25.
(Reference as Item 20)
21. Demonstrate compliance with the Utilization Management policies regarding prospective
patient review safety, reversal of certification determinations and the frequency of continued
reviews as described in UM 26, UM 27 and UM 28.
(Reference as Item 21)
22. Demonstrate compliance regarding the information upon which UM is conducted that
illustrate the requirements applicable to the scope of review information, the prospective,
retrospective and concurrent review determinations, and the lack of information policies and
procedures as stated within UM 29, UM 30, UM 31, and UM 32.
(Reference as Item 22)
23. Submit written policy and procedure documents that clearly detail the following:
33 Non-Certification Appeals Process, 34 Appeals process, 35 Appeal Peer Reviewer
Qualifications, 36 Drug U.M. appeals - Reviewer Qualifications, 37 Reviewer Attestation,
38 Expedited Appeals Process and Time Frame, 39 Standard Appeal Process and Time Frame,
40 Written Notice of Upheld Non-Certifications, 44 Appeal Records Documentation.
UM 33 through UM 41.
(Reference as Item 23)
24. Please explain how the organization complies with the option of a waiver for a second level
of appeal as required within K.S.A. 40-22a09a(c).
Please explain how the organization complies with the requirements of K.S.A. 40-22a07
regarding prior notification requirements for in-patient and outpatient hospital admissions in
the event of an unstable or uncommunicative patient.
(Reference Item 24)
Certification and Verification State of:
County of:
I, being duly sworn, state that I have read, and the applicant will comply with the provisions of
K.S.A. 40-22a01, et seq. and amendments thereto, and K.A.R. 40-4-41, as they relate to this
application; that I have read this application and know its contents and its attachments; that to
the best of my knowledge, belief and understanding, the statements made upon this
application and any attachments are true, complete, current, and correct in every material
respect, and do not contain any statement which, under the circumstances under which it was
made, would be false or misleading in respect to any material fact; and that I agree the
applicant will abide by the policies, procedures, and protocols described in and attached to this
application.
Name of Chief Executive Officer (Please Print or Type)
Original Signature
Subscribed and sworn before me this
day of
, 20
Signature, Notary Public
My commission expires on
, 20
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