Kansas Statutes 40-3229. Prior authorization requirements for emergency medical treatment; duties and responsibilities of organization, enrollees and participating providers; resolution of disputes
(a) A health maintenance organization that requires prior authorization before making payment for the treatment of medical emergency conditions, as defined by the health maintenance organization, shall provide enrollees with a toll-free telephone number answered 24 hours per day, seven days a week. At least one person with medical training who is authorized to determine whether an emergency condition exists shall be available 24 hours per day, seven days a week to make these determinations.
(b) A health maintenance organization shall not base its denial of payment for emergency medical services solely on the failure of the enrollee to receive authorization prior to receiving the emergency medical service. The enrollee must notify the health maintenance organization of receipt of medical services for emergency conditions within 24 hours or as soon after that as is reasonably possible. Nothing shall require the health maintenance organization to authorize payment for any services provided during that 24 hour period, regardless of medical necessity, if those services do not otherwise constitute benefits under the certificate of coverage approved by the commissioner.
Terms Used In Kansas Statutes 40-3229
- Certificate of coverage: means a statement of the essential features and services of the health maintenance organization coverage which is given to the subscriber by the health maintenance organization, medicare provider organization or by the group contract holder. See Kansas Statutes 40-3202
- Commissioner: means the commissioner of insurance of the state of Kansas. See Kansas Statutes 40-3202
- Enrollee: means a person who has entered into a contractual arrangement or on whose behalf a contractual arrangement has been entered into with a health maintenance organization or the medicare provider organization for health care services. See Kansas Statutes 40-3202
- Grievance: means a written complaint submitted in accordance with the formal grievance procedure by or on behalf of the enrollee regarding any aspect of the health maintenance organization or the medicare provider organization relative to the enrollee. See Kansas Statutes 40-3202
- Health maintenance organization: means an organization which:
(1) Provides or otherwise makes available to enrollees health care services, including at a minimum those basic health care services which are determined by the commissioner to be generally available on an insured or prepaid basis in the geographic area served;
(2) is compensated, except for reasonable copayments, for the provision of basic health care services to enrollees solely on a predetermined periodic rate basis;
(3) provides physician services directly through physicians who are either employees or partners of such organization or under arrangements with a physician or any group of physicians or under arrangements as an independent contractor with a physician or any group of physicians;
(4) is responsible for the availability, accessibility and quality of the health care services provided or made available. See Kansas Statutes 40-3202
- Person: means any natural or artificial person including but not limited to individuals, partnerships, associations, trusts or corporations. See Kansas Statutes 40-3202
- Provider: means any physician, hospital or other person which is licensed or otherwise authorized in this state to furnish health care services. See Kansas Statutes 40-3202
(c) If the participating provider is responsible for seeking prior authorization from the health maintenance organization before receiving payment for the treatment of emergency medical conditions and the enrollee is eligible at the time when covered services are provided, then the enrollee will not be held financially responsible for payment for covered services if the prior authorization for emergency medical services has not been sought and received, other than for what the enrollee would otherwise be responsible, such as copayments and deductibles.
(d) All disputes between an enrollee and a health maintenance organization arising under the provisions of this section shall be resolved by means of the grievance procedures established by the health maintenance organization.