1. Legal Name of Applicant:
Direct Phone Number:
Toll Free Number:
2. Is the applicant accreditated by and adhering to the health utilization management standards approved by URAC? YES
If so, please provide a copy of the current URAC accreditation certification for this application by email to firstname.lastname@example.org
Answer questions 7, 8 and 9 on page two and complete the final page. There is no fee if currently accredited by URAC.
K.S.A. 40-a04(b)(1) requires the signature of the Chief Executive Officer, President, or other head official of the applicant.
The following must be provided in the order stated below by email to email@example.com, with consecutive cross-referenced tabs as directed. A general UM program description alone is not sufficient.
3. Provide a certified copy of the URO’s charter or articles of incorporation and bylaws.
(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
(Reference as item 5)
6. Please provide qualifications of individuals performing utilization review at the location(s)
identified in item 4. This summary should be a spreadsheet of all staff who perform utilization
review services and include the 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, and State of
licensure. Please also include columns for the expiration and renewal date of certification/licensure.
(Reference as item 6)
7. Has the applicant, or any of its 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, or business license denied, suspended, or revoked by any public authority in this or any other state? YES
If yes, provide an explanation including amount of fine(s) and summary judgement order identification reference(s).
(Reference as item 7)
A. Identify vendor(s) to which reviews are outsourced and the services provided by namedvendor.
B. Does the applicant entry share common ownership, management, or control of anyvendor named above? YES
NO If so, please describe.
C. Is the applicant company a subsidiary of another URO or TPA organization? YES
NO If so, please identify.
D. Is the applicant company an affiliate of any insurance company? YES
NO If so, please identify.
(Reference as item 8)
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 the review is
limited, such as Dental only, Behavioral Health only, etc.
(Reference as item (9)
CORE STANDARDS 1 THROUGH 40.
Demonstrate compliance with each Core Standard as required by K.A.R. 40-4-41 by submitting the applicant’s policies and procedures (P&P) for each Core Standards 1 – 40. P&P’s must clearly identify the applicant’s name. NOTE: an affiliated entity’s P&P is not acceptable. A general UM program description alone is not sufficient. Each core must be separated by tabs as follows:
Tab 1 - Organizational structure (include chart) -
Cores 1 and 2
Tab 2 - Policies and Procedures (include master list) -
Tab 3 - Regulatory Compliance - Core 4
Tab 4 - InterDepartmental 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 - Cores 11 and 12
Tab 8 - Information Management - Cores 13 through 16
Tab 9 - Quality Management - Cores 17 through 14
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 4 - Consumer Protection & Empowerment - Cores 37 through 40
(Reference as Item 10)
HEALTH UTILIZATION MANAGEMENT STANDARDS 1 THROUGH 41
Submit 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 UM5.
(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 UM7, UM8 and, UM9
(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 UM10, UM11, 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 UM13, UM14, UM15, and UM16 and highlight where each is located
(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 UM17 and UM18.
(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 UM19, UM20 and UM21.
(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 UM22 and UM23.
(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 UM24 and UM25.
(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 UM26, UM27 and UM28.
(Reference as Item 21)
22. Demonstrate compliance with information upon which UM is Conducted and highlight the location of the requirements applicable to the scope of review information, the prospective, retrospective, and concurrent review determinations, and lack of information policies and procedures as stated within UM29, UM30, UM31, and UM32.
(Reference as Item 22)
23. Submit written policy and procedure documents that detail the following and highlight where each is located:
UM33 Non-Certification Appeals Process, UM34 Appeals process, UM35 Appeal PeerReviewer Qualifications, UM36 Drug U.M. appeals - Reviewer Qualifications, UM37 Reviewer Attestation, UM38 Expedited Appeals Process and Time Frame, UM39 Standard Appeal Process and Time Frame, UM40 Written Notice of Upheld Non-Certifications, UM41 Appeal Documentation UM33 through UM41.
(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)
Please submit all documentation as directed above, to support the new application and to
demonstrate compliance with Kansas law. Please email any such documents to:
I 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.
I declare (or verify, certify or state) under penalty of perjury under the laws of the state of
Kansas that the foregoing is true and correct. Executed on:
Name of Chief Executive Officer:
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.