40-22a06. Same; certificate not required for certain review activities; certain provisions not applicable to certain organizations. (a) No certificate shall be required for utilization review activities conducted by or on behalf of:

(1) An agency of the federal government;

(2) a person, agency or utilization review organization acting on behalf of the federal government, but only to the extent such person, agency or organization is providing services under federal regulation;

(3) a federally qualified health maintenance organization authorized to transact business in Kansas which is administering a quality assurance program and performing utilization review activities for its own members as required by 42 U.S.C. § 300e(c)(8) and 42 U.S.C. § 300e(c)(6) respectively;

(4) a person employed or used by a utilization review organization authorized to perform utilization review in Kansas, including, but not limited to, individual nurses and other health care providers. This exemption shall not apply with respect to individual persons performing utilization review activities in conjunction with any insurance contract or health benefit plan pursuant to a direct contractual relationship with a health maintenance organization, group-funded self-insurance plan or insurance company;

(5) a health benefit plan that is self-insured and qualified under the federal employee retirement income security act of 1974 as amended;

(6) hospitals, home health agencies, clinics, private health care provider offices or any other authorized health care facility or entity conducting general, in-house utilization review unless such review is for the purpose of approving or denying payment for hospital or medical services in a particular case; or

(7) utilization review organizations conducting utilization review only with respect to mental health, chemical dependency, chiropractic, optometric, podiatric, dental or any other health care service or services other than the practice of medicine and surgery, until utilization review standards governing such treatment or service are incorporated in rules and regulations adopted pursuant to K.S.A. 40-22a04, and amendments thereto.

(b) The provisions of K.S.A. 40-22a04 (b)(2), (3), (4), (5), (6) and subsection (c), and amendments thereto, shall not apply to:

(1) Utilization review organizations accredited by and adhering to the national utilization review standards approved by the American accreditation health care commission; or

(2) such other utilization review organizations as the advisory committee may recommend and the commissioner approves.

History: L. 1994, ch. 238, § 6; L. 1998, ch. 14, § 1; July 1.