2013 Kentucky Revised Statutes CHAPTER 304 - INSURANCE CODE Subtitle 18 - Group and Blanket Health Insurance 18.18-045 Requirements for insurer that issues policy or administers program providing for utilization review of benefits.
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304.18-045 Requirements for insurer that issues policy or administers
program providing for utilization review of benefits.
(1)
(2)
Every health insurer proposing to issue or deliver in this state a group or
blanket health insurance policy or contract or administer a health benefit
program which provides for the coverage of hospital benefits and the utilization
review of those benefits by an insurer, its designee, or a private review agent
shall:
(a) Be registered 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,
304.17A-607, 304.17A-609, 304.17A-611, 304.17A-613, and 304.17A-615, an
insurer or its designee 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 insurer is in compliance with subsection (1) of this section.
Effective:July 14, 2000
History: Amended 2000 Ky. Acts ch. 262, sec. 28, effective July 14, 2000. -Amended 1998 Ky. Acts ch. 426, sec. 526, effective July 15, 1998. -- Amended
1996 Ky. Acts ch. 353, sec. 2, effective July 15, 1996. -- Created 1990 Ky. Acts
ch. 451, sec. 8, effective July 13, 1990.
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