2006 Kentucky Revised Statutes - .607   Duties of insurer or private review agent performing utilization reviews -- Requirement for registration -- Consequences of insurer\'s failure to make timely utilization review determination -- Requirement that insurer or private review agent submit changes to the office -- Requirement that private review agent provide timely notice of entities for whom it is providing review.

304.17A-607 Duties of insurer or private review agent performing utilization reviews -- Requirement for registration -- Consequences of insurer's failure to make timely utilization review determination -- Requirement that insurer or private review agent submit changes to the office -- Requirement that private review agent provide timely notice of entities for whom it is providing review. (1) An insurer or private review agent shall not provide or perform utilization reviews without being registered with the office. A registered insurer or private review agent shall: (a)  Have available the services of sufficient numbers of registered nurses, medical records technicians, or similarly qualified persons supported by licensed physicians with access to consultation with other appropriate physicians to carry out its utilization review activities; (b)  Ensure that only licensed physicians shall: 1. Make a utilization review decision to deny, reduce, limit, or terminate a health care benefit or to deny, or reduce payment for a health care service because that service is not medically necessary, experimental, or investigational except in the case of a health care service rendered by a chiropractor or optometrist where the denial shall be made respectively by a chiropractor or optometrist duly licensed in Kentucky; and 2. Supervise qualified personnel conducting case reviews; (c)  Have available the services of sufficient numbers of practicing physicians in appropriate specialty areas to assure the adequate review of medical and surgical specialty and subspecialty cases; (d)  Not disclose or publish individual medical records or any other confidential medical information in the performance of utilization review activities except as provided in the Health Insurance Portability and Accountability Act, Subtitle F, secs. 261 to 264 and 45 C.F.R. secs. 160 to 164 and other applicable laws and administrative regulations; (e)  Provide a toll free telephone line for covered persons, authorized persons, and providers to contact the insurer or private review agent and be accessible to covered persons, authorized persons, and providers for forty (40) hours a week during normal business hours in this state; (f)  Where an insurer, its agent, or private review agent provides or performs utilization review, be available to conduct utilization review during normal business hours and extended hours in this state on Monday and Friday through 6:00 p.m., including federal holidays; (g)  Provide decisions to covered persons, authorized persons, and all providers on appeals of adverse determinations and coverage denials of the insurer or private review agent, in accordance with this section and administrative regulations promulgated in accordance with KRS 304.17A-609; (h)  Except for retrospective review of an emergency admission where the covered person remains hospitalized at the time the review request is made, which shall be considered a concurrent review, provide a utilization review decision Page 1 of 3
relating to urgent and nonurgent care in accordance with 29 C.F.R. Part 2560, including the timeframes and written notice of the decision. A written notice in electronic format, including e-mail or facsimile, may suffice for this purpose where the covered person, authorized person, or provider has agreed in advance in writing to receive such notices electronically and shall include the required elements of subsection (j) of this section; (i)  Provide a utilization review decision within twenty-four (24) hours of receipt of a request for review of a covered person's continued hospital stay and prior to the time when a previous authorization for hospital care will expire; (j)  Provide written notice of review decisions to the covered person, authorized person, and providers. An insurer or agent that denies coverage or reduces payment for a treatment, procedure, drug that requires prior approval, or device shall include in the written notice: 1. A statement of the specific medical and scientific reasons for denial or reduction of payment or identifying that provision of the schedule of benefits or exclusions that demonstrates that coverage is not available; 2. The state of licensure, medical license number, and the title of the reviewer making the decision; 3. Except for retrospective review, a description of alternative benefits, services, or supplies covered by the health benefit plan, if any; and 4. Instructions for initiating or complying with the insurer's internal appeal procedure, as set forth in KRS 304.17A-617, stating, at a minimum, whether the appeal shall be in writing, and any specific filing procedures, including any applicable time limitations or schedules, and the position and phone number of a contact person who can provide additional information; (k)  Afford participating physicians an opportunity to review and comment on all medical and surgical and emergency room protocols, respectively, of the insurer and afford other participating providers an opportunity to review and comment on all of the insurer's protocols that are within the provider's legally authorized scope of practice; and (l)  Comply with its own policies and procedures on file with the office or, if accredited or certified by a nationally recognized accrediting entity, comply with the utilization review standards of that accrediting entity where they are comparable and do not conflict with state law. (2) The insurer's failure to make a determination and provide written notice within the time frames set forth in this section shall be deemed to be an adverse determination by the insurer for the purpose of initiating an internal appeal as set forth in KRS 304.17A-617. This provision shall not apply where the failure to make the determination or provide the notice results from circumstances which are documented to be beyond the insurer's control. (3) An insurer or private review agent shall submit a copy of any changes to its utilization review policies or procedures to the office. No change to policies and Page 2 of 3
procedures shall be effective or used until after it has been filed with and approved by the executive director. (4) A private review agent shall provide to the office the names of the entities for which the private review agent is performing utilization review in this state. Notice shall be provided within thirty (30) days of any change. Effective: July 13, 2004 History: Amended 2004 Ky. Acts ch. 59, sec. 12, effective July 13, 2004. -- Amended 2002 Ky. Acts ch. 181, sec. 5, effective July 15, 2002. -- Amended 2001 Ky. Acts ch. 145, sec. 2, effective June 21, 2001. -- Created 2000 Ky. Acts ch. 262, sec. 4, effective July 14, 2000. Legislative Research Commission Note (6/20/2005). 2005 Ky. Acts chs. 11, 85, 95, 97, 98, 99, 123, and 181 instruct the Reviser of Statutes to correct statutory references to agencies and officers whose names have been changed in 2005 legislation confirming the reorganization of the executive branch. Such a correction has been made in this section. Page 3 of 3

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