There is a newer version of the Kentucky Revised Statutes
2009 Kentucky Revised Statutes
Subtitle 17A. Health Benefit Plans
304.17A.613 Emergency administrative regulations governing registration of insurers and private review agents seeking to conduct utilization reviews -- Procedure for handling complaints.
Download pdfProcedure for handling complaints. (1) The department shall, through the promulgation of emergency administrative regulations, develop a process:
(a) For the review of applications for registration of insurers or private review agents seeking to conduct utilization reviews; (b) For the review of applications for insurers or private review agents seeking registration renewal to continue as a utilization review entity; (c) Ensuring that no registration shall be approved unless the commissioner has documentation or findings that all applicants seeking registration or renewal to
conduct utilization review are in compliance with the requirements and
procedures established regarding utilization review, and as to renewals, have
complied with KRS 304.17A-600 to 304.17A-633 and administrative
regulations promulgated to enforce and to administer KRS 304.17A-600 to
304.17A-633; and (d) Establishing fees for applications and renewals in an amount sufficient to pay the administrative costs of the program and any other costs associated with
carrying out the provisions of KRS 304.17A-600, 304.17A-603, 304.17A-605,
304.17A-607, 304.17A-609, 304.17A-611, 304.17A-613, and 304.17A-615. (2) The registration issued in accordance with this section expires on the second anniversary of the effective date unless it is renewed. (3) The registration issued under this section is not transferable.
(4) The commissioner may revoke or suspend the utilization review registration of any insurer or private review agent who does not comply with the requirements and
procedures established regarding utilization review or any administrative
regulations promulgated thereunder. (5) The department shall establish reporting requirements to: (a) Evaluate the effectiveness of insurers and private review agents; and
(b) Determine if the utilization review plans are in compliance with the requirements and procedures established regarding utilization review and
applicable administrative regulations. (6) Upon request of any provider, authorized person, or covered person whose care is subject to review, the department shall provide copies of policies or procedures of
any insurer or private review agent that has been issued a registration by the
department to conduct review in this state. (7) Notwithstanding any provision to the contrary, an insurer or private review agent registered and in good standing under the provisions of KRS 211.461 to 211.466,
prior to July 14, 2000, shall be deemed in compliance with requirements and
procedures established in KRS 304.17A-600 to 304.17A-633 regarding utilization
review and registered accordingly. Page 2 of 2 (8) Upon receipt of written complaints from covered persons, authorized persons, or providers stating that an insurer or a private review agent has failed to perform a
review in accordance with the utilization review plan or the requirements and
procedures established regarding utilization review, or administrative regulations
promulgated thereunder, the commissioner shall:
(a) Send a copy of the complaint to the insurer or the private review agent within ten (10) days of receipt of the complaint, and require that any written reply be
sent to the commissioner within ten (10) days; and (b) Review the complaint and any written reply received from the insurer or private review agent within the time frames set forth in paragraph (a) of this
subsection and make a recommendation to the insurer or private review agent
and the covered person, authorized person, or provider. (9) The commissioner shall consider complaints before issuing or renewing any registration or renewal of a registration to an insurer or a private review agent. (10) Notwithstanding any provision in this section to the contrary, the department shall accept accreditation or certification by a nationally recognized accreditation
organization as sufficient documentation or finding for purposes of subsections (1)
and (5) of this section that the insurer or private review agent meets the application
requirements for registration or renewal. Insurers or private review agents
accredited or certified by a nationally recognized accreditation organization shall be
deemed compliant with the utilization review and internal appeals requirements of
this section and KRS 304.17A-600, 304.17A-607, 304.17A-609, 304.17A-617,
304.17A-623, and 304.17A-625 and administrative regulations to the extent the
standards of such nationally recognized accreditation organization sufficiently meet
these requirements. The department shall have a simplified process in
administrative regulations for insurers and private review agents to register using
accreditation or certification and shall limit any additional documentation only for
demonstrating compliance with requirements in this section and KRS 304.17A-600,
304.17A-607, 304.17A-609, 304.17A-617, 304.17A-623, and 304.17A-625 not met
by the standards of a nationally recognized accreditation organization. Effective: July 15, 2010
History: Amended 2010 Ky. Acts ch. 24, sec. 1238, effective July 15, 2010. -- Amended 2002 Ky. Acts ch. 181, sec. 7, effective July 15, 2002. -- Created 2000 Ky.
Acts ch. 262, sec. 7, effective July 14, 2000.
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