There is a newer version of the Kentucky Revised Statutes
2009 Kentucky Revised Statutes
Subtitle 17A. Health Benefit Plans
304.17A.716 Prohibition against denial or reduction of payment for covered health benefit -- Conditions.
Download pdfunder the covered person's health benefit plan if:
(a) The covered person's provider, during normal business hours, contacts the insurer or the insurer's designee or agent on the day the covered person is
expected to be discharged to request review of the covered person's continued
hospitalization and the insurer, designee, or agent fails to provide a utilization
review decision within twenty-four (24) hours of the request and prior to the
time upon which any previous authorization will expire; or (b) 1. The covered person's provider makes at least three (3) documented
attempts during a four (4) consecutive hour period to contact the insurer,
designee, or agent during normal business hours to request:
a. Review of a continued hospital stay; b. Preauthorization of treatment for a covered person who is already
hospitalized; or c. Retrospective review of an emergency hospital admission where
the covered person remains hospitalized at the time the review
requested is made; and 2. The insurer, designee, or private review agent fails to be accessible via a
toll-free telephone line for forty (40) hours per week during normal
business hours. (2) The insurer's liability to pay for the covered person's hospitalization under the circumstances set forth in subsection (1) of this section shall extend until the
insurer, designee, or private review agent issues a utilization review decision on a
request for review of the matters addressed under subsection (1)(b) of this section. (3) The insurer's liability to pay under this section shall be conditioned on: (a) The provider establishing verifiable documentation of the contact with, and subsequent failure of the insurer, designee, or agent to make the utilization
review decision as set forth in subsection (1)(a) of this section; or (b) The provider establishing verifiable documentation of the attempt to make contact with the insurer, designee, or agent as addressed in subsection (1)(b)
of this section. (4) In either instance, the contact or attempts to contact, as set forth in this section, shall be made by the means required by the insurer, designee, or agent for requesting
utilization review. (5) This section applies only when the request for review concerns covered health benefits, and it shall not supersede any limitations or exclusions in the covered
person's health benefit plan. This section shall not apply if, in requesting a review,
the provider does not furnish the information requested by the insurer or agent to Page 2 of 2 make a utilization review decision or if actions by the provider impede an insurer's
or private review agent's ability to issue a utilization review decision. Effective: July 14, 2000
History: Created 2000 Ky. Acts ch. 436, sec. 9, effective July 14, 2000.
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