2009 Kentucky Revised Statutes Subtitle 17A. Health Benefit Plans 304.17A.700 Definitions for KRS 304.17A-700 to 304.17A-730 and KRS 205.593, 304.14-135, and 304.99-123.
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304.17A-700 Definitions for KRS 304.17A-700 to 304.17A-730 and KRS 205.593,
304.14-135, and 304.99-123.
As used in KRS 304.17A-700 to 304.17A-730 and KRS 205.593, 304.14-135, and <br>304.99-123: <br>(1) "Adjudicate" means an insurer pays, contests, or denies a clean claim; <br>(2) "Claims payment time frame" means the time period prescribed under KRS
304.17A-702 following receipt of a clean claim from a provider at the address <br>published by the insurer, whether it is the address of the insurer or a delegated <br>claims processor, within which an insurer is required to pay, contest, or deny a <br>health care claim;
(3) "Clean claim" means a properly completed billing instrument, paper or electronic,
including the required health claim attachments, submitted in the following <br>applicable form: <br>(a) A clean claim from an institutional provider shall consist of:
1.
The UB-92 data set or its successor submitted on the designated paper or <br>electronic format as adopted by the NUBC;
2.
Entries stated as mandatory by the NUBC; and
3.
Any state-designated data requirements determined and approved by the <br>Kentucky State Uniform Billing Committee and included in the UB-92 <br>billing manual effective at the time of service.
(b) A clean claim for dentists shall consist of the form and data set approved by
the American Dental Association.
(c) A clean claim for all other providers shall consist of the HCFA 1500 data set
or its successor submitted on the designated paper or electronic format as <br>adopted by the National Uniform Claims Committee.
(d) A clean claim for pharmacists shall consist of a universal claim form and data
set approved by the National Council on Prescription Drug Programs;
(4) "Commissioner" means the commissioner of the Department of Insurance; <br>(5) "Covered person" means a person on whose behalf an insurer offering a health
benefit plan is obligated to pay benefits or provide services;
(6) "Department" means the Department of Insurance; <br>(7) "Electronic" or "electronically" means electronic mail, computerized files,
communications, or transmittals by way of technology having electrical, digital, <br>magnetic, wireless, optical, electromagnetic, or similar capabilities;
(8) "Health benefit plan" has the same meaning as provided in KRS 304.17A-005; <br>(9) "Health care provider" or "provider" means a provider licensed in Kentucky as
defined in KRS 304.17A-005 and, for the purposes of KRS 304.17A-700 to <br>304.17A-730 and KRS 205.593, 304.14-135, and 304.99-123 only, shall include <br>physical therapists licensed under KRS Chapter 327, psychologists licensed under <br>KRS Chapter 319, and social workers licensed under KRS Chapter 335. Nothing <br>contained in KRS 304.17A-700 to 304.17A-730 and KRS 205.593, 304.14-135, and
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304.99-123 shall be construed to include physical therapists, psychologists, and <br>social workers as a health care provider or provider under KRS 304.17A-005;
(10) "Health claim attachments" means medical information from a covered person's
medical record required by the insurer containing medical information relating to <br>the diagnosis, the treatment, or services rendered to the covered person and as may <br>be required pursuant to KRS 304.17A-720;
(11) "Institutional provider" means a health care facility licensed under KRS Chapter
216B;
(12) "Insurer" has the same meaning provided in KRS 304.17A-005; <br>(13) "Kentucky Uniform Billing Committee (KUBC)" means the committee of health
care providers, governmental payors, and commercial insurers established as a local <br>arm of NUBC to implement the bill requirements of the NUBC and to prescribe any <br>additional billing requirements unique to Kentucky insurers;
(14) "National Uniform Billing Committee (NUBC)" means the national committee of
health care providers, governmental payors, and commercial insurers that develops <br>the national uniform billing requirements for institutional providers as referenced in <br>accordance with the Federal Health Insurance Portability and Accountability Act of <br>1996, 42 U.S.C. Chapter 6A, Subchapter XXV, secs. 300gg et seq.;
(15) "Retrospective review" means utilization review that is conducted after health care
services have been provided to a covered person; and
(16) "Utilization review" has the same meaning as provided in KRS 304.17A-600(18).
Effective: July 15, 2010 <br>History: Amended 2010 Ky. Acts ch. 24, sec. 1248, effective July 15, 2010. --
Amended 2004 Ky. Acts ch. 59, sec. 16, effective July 13, 2004. -- Amended 2002 <br>Ky. Acts ch. 181, sec. 11, effective July 15, 2002. -- Created 2000 Ky. Acts ch. 436, <br>sec. 1, effective July 14, 2000.
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