Name of Utilization Review Organization: Request for continuation of certification for period ending: Review the following, provide your acknowledgement and a copy of your current URAC Certification by email to kdoi.rf@ks.gov As a reminder, the Commissioner may visit and examine the affairs of any URO to determine if the organization is in compliance with Kansas law. Any URO so examined shall pay the reasonable and proper charges incurred for such examination, including the actual expenses of the insurance commissioner or the expenses and compensation of the Commissioner's authorized representative and the expenses and compensation of assistants and examiners employed therein. Has the Utilization Review Organization undergone any changes that would affect its legal authority to maintain a certificate pursuant to K.S.A. 40-22a04? Since the last continuation date, have there been any changes to the Utilization Review Organization’s: URAC accreditation status Change in entity Legal Name Any judgement and/or fines issued by any other state agency in the past year.
If the answer to any of these is checked, please submit all documentation to support the new condition and to demonstrate compliance with Kansas law. Please email any additional documents to kdoi.rf@ks.gov
The undersigned certifies they have executed this application dated for and on behalf of the Utilization Review Organization, that they are a duly appointed representative of such URO, that they are authorized to execute and file this application, and that the information contained in this application is true and accurate to the best of their knowledge. Signature: By typing your name above, you are signing this electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this form. Name: Contact Phone Number and Email Address: (Phone) (Email)
