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304.17A-600 Definitions for KRS 304.17A-600 to 304.17A-633.
As used in KRS 304.17A-600 to 304.17A-633: <br>(1) (a) "Adverse determination" means a determination by an insurer or its designee
that the health care services furnished or proposed to be furnished to a covered <br>person are: <br>1.
Not medically necessary, as determined by the insurer, or its designee or <br>experimental or investigational, as determined by the insurer, or its <br>designee; and
2.
Benefit coverage is therefore denied, reduced, or terminated.
(b) "Adverse determination" does not mean a determination by an insurer or its
designee that the health care services furnished or proposed to be furnished to <br>a covered person are specifically limited or excluded in the covered person's <br>health benefit plan;
(2) "Authorized person" means a parent, guardian, or other person authorized to act on
behalf of a covered person with respect to health care decisions;
(3) "Concurrent review" means utilization review conducted during a covered person's
course of treatment or hospital stay;
(4) "Covered person" means a person covered under a health benefit plan; <br>(5) "External review" means a review that is conducted by an independent review entity
which meets specified criteria as established in KRS 304.17A-623, 304.17A-625, <br>and 304.17A-627;
(6) "Health benefit plan" means the document evidencing and setting forth the terms
and conditions of coverage of any hospital or medical expense policy or certificate; <br>nonprofit hospital, medical-surgical, and health service corporation contract or <br>certificate; provider sponsored integrated health delivery network policy or <br>certificate; a self-insured policy or certificate or a policy or certificate provided by a <br>multiple employer welfare arrangement, to the extent permitted by ERISA; health <br>maintenance organization contract; or any health benefit plan that affects the rights <br>of a Kentucky insured and bears a reasonable relation to Kentucky, whether <br>delivered or issued for delivery in Kentucky, and does not include policies covering <br>only accident, credit, dental, disability income, fixed indemnity medical expense <br>reimbursement policy, long-term care, Medicare supplement, specified disease, <br>vision care, coverage issued as a supplement to liability insurance, insurance arising <br>out of a workers' compensation or similar law, automobile medical-payment <br>insurance, insurance under which benefits are payable with or without regard to <br>fault and that is statutorily required to be contained in any liability insurance policy <br>or equivalent self-insurance, student health insurance offered by a Kentucky-<br>licensed insurer under written contract with a university or college whose students it <br>proposes to insure, medical expense reimbursement policies specifically designed to <br>fill gaps in primary coverage, coinsurance, or deductibles and provided under a <br>separate policy, certificate, or contract, or coverage supplemental to the coverage <br>provided under Chapter 55 of Title 10, United States Code; or limited health service
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benefit plans; and for purposes of KRS 304.17A-600 to 304.17A-633 includes <br>short-term coverage policies;
(7) "Independent review entity" means an individual or organization certified by the
department to perform external reviews under KRS 304.17A-623, 304.17A-625, <br>and 304.17A-627;
(8) "Insurer" means any of the following entities authorized to issue health benefit plans
as defined in subsection (6) of this section: an insurance company, health <br>maintenance organization; self-insurer or multiple employer welfare arrangement <br>not exempt from state regulation by ERISA; provider-sponsored integrated health <br>delivery network; self-insured employer-organized association; nonprofit hospital, <br>medical-surgical, or health service corporation; or any other entity authorized to <br>transact health insurance business in Kentucky;
(9) "Internal appeals process" means a formal process, as set forth in KRS 304.17A-
617, established and maintained by the insurer, its designee, or agent whereby the <br>covered person, an authorized person, or a provider may contest an adverse <br>determination rendered by the insurer, its designee, or private review agent;
(10) "Nationally recognized accreditation organization" means a private nonprofit entity
that sets national utilization review and internal appeal standards and conducts <br>review of insurers, agents, or independent review entities for the purpose of <br>accreditation or certification. Nationally recognized accreditation organizations <br>shall include the National Committee for Quality Assurance (NCQA), the American <br>Accreditation Health Care Commission (URAC), the Joint Commission on <br>Accreditation of Healthcare Organizations (JCAHO), or any other organization <br>identified by the department;
(11) "Private review agent" or "agent" means a person or entity performing utilization
review that is either affiliated with, under contract with, or acting on behalf of any <br>insurer or other person providing or administering health benefits to citizens of this <br>Commonwealth. "Private review agent" or "agent" does not include an independent <br>review entity which performs external review of adverse determinations;
(12) "Prospective review" means utilization review that is conducted prior to a hospital
admission or a course of treatment;
(13) "Provider" shall have the same meaning as set forth in KRS 304.17A-005; <br>(14) "Qualified personnel" means licensed physician, registered nurse, licensed practical
nurse, medical records technician, or other licensed medical personnel who through <br>training and experience shall render consistent decisions based on the review <br>criteria;
(15) "Registration" means an authorization issued by the department to an insurer or a
private review agent to conduct utilization review;
(16) "Retrospective review" means utilization review that is conducted after health care
services have been provided to a covered person. "Retrospective review" does not <br>include the review of a claim that is limited to an evaluation of reimbursement <br>levels, or adjudication of payment;
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(17) (a) "Urgent care" means health care or treatment with respect to which the
application of the time periods for making nonurgent determination: <br>1.
Could seriously jeopardize the life or health of the covered person or the <br>ability of the covered person to regain maximum function; or
2.
In the opinion of a physician with knowledge of the covered person's <br>medical condition, would subject the covered person to severe pain that <br>cannot be adequately managed without the care or treatment that is the <br>subject of the utilization review; and
(b) "Urgent care" shall include all requests for hospitalization and outpatient
surgery;
(18) "Utilization review" means a review of the medical necessity and appropriateness of
hospital resources and medical services given or proposed to be given to a covered <br>person for purposes of determining the availability of payment. Areas of review <br>include concurrent, prospective, and retrospective review; and
(19) "Utilization review plan" means a description of the procedures governing
utilization review activities performed by an insurer or a private review agent.
Effective: July 15, 2010 <br>History: Amended 2010 Ky. Acts ch. 24, sec. 1235, effective July 15, 2010. --
Amended 2004 Ky. Acts ch. 59, sec. 11, effective July 13, 2004. -- Amended 2002 <br>Ky. Acts ch. 181, sec. 4, effective July 15, 2002. -- Created 2000 Ky. Acts ch. 262, <br>sec. 1, effective July 14, 2000.
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