2012 Kentucky Revised Statutes CHAPTER 304 INSURANCE CODE SUBTITLE 38. Health Maintenance Organizations 38..225 Requirements for health maintenance organization that provides hospital benefits coverage and requires utilization review of benefits.
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304.38-225 Requirements for health maintenance organization that provides
hospital benefits coverage and requires utilization review of benefits.
(1)
(2)
Every health maintenance organization in this state which provides coverage of
hospital benefits and requires the utilization review of such benefits or administers a
health benefit program which provides for the coverage of hospital benefits and
requires the utilization review of such benefits by a private review agent shall:
(a) Be a registered private review agent in accordance with KRS 304.17A-607
and administrative regulations promulgated under the authority of KRS
304.17A-613; or
(b) Contract with a private review agent that has been registered in accordance
with KRS 304.17A-607 and administrative regulations promulgated under the
authority of KRS 304.17A-613.
Notwithstanding any other provision of KRS 304.17A-603, 304.17A-605, 304.17A607, 304.17A-609, 304.17A-611, 304.17A-613, and 304.17A-615, a health
maintenance organization shall not deny or reduce payment of health benefits to any
person, licensed practitioner, or health facility for covered services which have been
rendered to an insured unless:
(a) Notice of denial has been issued. The notice shall inform patients, authorized
persons, and health-care providers of their right to appeal adverse
determinations of a utilization review by the insurer, its designee, or private
review agent to the insurer for the internal review process established by the
insurer in accordance with KRS 304.17A-617 and 304.17A-619. The notice
shall also include instructions on filing an internal appeal; and
(b) The health maintenance organization is in compliance with subsection (1) of
this section.
Effective: July 14, 2000
History: Amended 2000 Ky. Acts ch. 262, sec. 31, effective July 14, 2000. -- Amended
1998 Ky. Acts ch. 426, sec. 528, effective July 15, 1998. -- Amended 1996 Ky. Acts
ch. 353, sec. 4, effective July 15, 1996. -- Created 1990 Ky. Acts ch. 451, sec. 11,
effective July 13, 1990.
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