2014 Kentucky Revised Statutes CHAPTER 304 - INSURANCE CODE Subtitle 17A - Health Benefit Plans 17A.17A-545 Medical director for managed care plan -- Duties -- Quality assurance or improvement standards -- Process to select health care providers -- Uniform application form and guidelines for health care provider evaluations.
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304.17A-545 Medical director for managed care plan -- Duties -- Quality
assurance or improvement standards -- Process to select health care
providers -- Uniform application form and guidelines for health care
provider evaluations.
(1)
(2)
(3)
A managed care plan shall appoint a medical director who:
(a) Is a physician licensed to practice in this state;
(b) Is in good standing with the State Board of Medical Licensure;
(c) Has not had his or her license revoked or suspended, under KRS
311.530 to 311.620;
(d) Shall sign any denial letter required under KRS 304.17A-540; and
(e) Shall be responsible for the treatment policies, protocols, quality
assurance activities, and utilization management decisions of the plan.
The medical director shall ensure that:
(a) Any utilization management decision to deny, reduce, or terminate a
health care benefit or to deny payment for a health care service because
that service is not medically necessary shall be made by a physician,
except in the case of a health care service rendered by a chiropractor or
optometrist, that decision shall be made respectively by a chiropractor or
optometrist duly licensed in Kentucky;
(b) A utilization management decision shall not retrospectively deny
coverage for health care services provided to a covered person when
prior approval has been obtained from the insurer for those services,
unless the approval was based upon fraudulent, materially inaccurate, or
misrepresented information submitted by the covered person or the
participating provider;
(c) In the case of a managed care plan, a procedure is implemented whereby
participating physicians have an opportunity to review and comment on all
medical and surgical and emergency room protocols, respectively, of the
insurer and whereby other participating providers have an opportunity to
review and comment on all of the insurer's protocols that are within the
provider's legally authorized scope of practice;
(d) The utilization management program is available to respond to
authorization requests for urgent services and is available, at a minimum,
during normal working hours for inquiries and authorization requests for
nonurgent health care services; and
(e) In the case of a managed care plan, a covered person is permitted to
choose or change a primary care provider from among participating
providers in the provider network and, when appropriate, choose a
specialist from among participating network providers following an
authorized referral, if required by the insurer, and subject to the ability of
the specialist to accept new patients.
A managed care plan shall develop comprehensive quality assurance or
improvement standards adequate to identify, evaluate, and remedy problems
relating to access, continuity, and quality of health care services. These
standards shall be made available to the public during regular business hours
(4)
(5)
(6)
and include:
(a) An ongoing written, internal quality assurance or improvement program;
(b) Specific written guidelines for quality of care studies and monitoring,
including attention to vulnerable populations;
(c) Performance and clinical outcomes-based criteria;
(d) A procedure for remedial action to correct quality problems, including
written procedures for taking appropriate corrective action;
(e) A plan for data gathering and assessment; and
(f) A peer review process.
Each managed care plan shall have a process for the selection of health care
providers who will be on the plan's list of participating providers, with written
policies and procedures for review and approval used by the plan.
(a) The plan shall establish minimum professional requirements for
participating health care providers. An insurer may not discriminate
against a provider solely on the basis of the provider's license by the
state;
(b) The plan shall demonstrate that it has consulted with appropriately
qualified health care providers to establish the minimum professional
requirements;
(c) The plan's selection process shall include verification of each health care
provider's license, history of license suspension or revocation, and liability
claims history;
(d) A managed care plan shall establish a formal written, ongoing process for
the reevaluation of each participating health care provider within a
specified number of years after the provider's initial acceptance into the
plan. The reevaluation shall include an update of the previous review
criteria and an assessment of the provider's performance pattern based
on criteria such as enrollee clinical outcomes, number of complaints, and
malpractice actions.
The commissioner shall promulgate administrative regulations to establish a
uniform application form and guidelines for the evaluation and reevaluation of
health care providers, including psychologists, who will be on the plan's list of
participating providers in accordance with subsection (4) of this section. In
developing a uniform application and guidelines, the department shall consider
industry standards and guidelines adopted by the Council for Affordable Quality
Healthcare. The uniform application form and guidelines shall be used by all
insurers.
A managed care plan shall not use a health care provider beyond, or outside
of, the provider's legally authorized scope of practice.
Effective:July 15, 2010
History: Amended 2010 Ky. Acts ch. 24, sec. 1231, effective July 15, 2010. -Amended 2005 Ky. Acts ch. 144, sec. 8, effective June 20, 2005. -- Amended
2000 Ky. Acts ch. 383, sec. 1, effective July 14, 2000; and ch. 521, sec. 17,
effective July 14, 2000. -- Created 1998 Ky. Acts ch. 496, sec. 34, effective April
10, 1998.
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