Download as PDF
304.17A-600 Definitions for KRS 304.17A-600 to 304.17A-633.
As used in KRS 304.17A-600 to 304.17A-633:
(1) (a) "Adverse determination" means a determination by an insurer or its
designee that the health care services furnished or proposed to be
furnished to a covered person are:
1.
Not medically necessary, as determined by the insurer, or its
designee or experimental or investigational, as determined by the
insurer, or its designee; and
2.
Benefit coverage is therefore denied, reduced, or terminated.
(b) "Adverse determination" does not mean a determination by an insurer or
its designee that the health care services furnished or proposed to be
furnished to a covered person are specifically limited or excluded in the
covered person's health benefit plan;
(2) "Authorized person" means a parent, guardian, or other person authorized to
act on behalf of a covered person with respect to health care decisions;
(3) "Concurrent review" means utilization review conducted during a covered
person's course of treatment or hospital stay;
(4) "Covered person" means a person covered under a health benefit plan;
(5) "External review" means a review that is conducted by an independent review
entity which meets specified criteria as established in KRS 304.17A-623,
304.17A-625, and 304.17A-627;
(6) "Health benefit plan" means the document evidencing and setting forth the
terms and conditions of coverage of any hospital or medical expense policy or
certificate; nonprofit hospital, medical-surgical, and health service corporation
contract or certificate; provider sponsored integrated health delivery network
policy or certificate; a self-insured policy or certificate or a policy or certificate
provided by a multiple employer welfare arrangement, to the extent permitted
by ERISA; health maintenance organization contract; or any health benefit plan
that affects the rights of a Kentucky insured and bears a reasonable relation to
Kentucky, whether delivered or issued for delivery in Kentucky, and does not
include policies covering only accident, credit, dental, disability income, fixed
indemnity medical expense reimbursement policy, long-term care, Medicare
supplement, specified disease, vision care, coverage issued as a supplement
to liability insurance, insurance arising out of a workers' compensation or
similar law, automobile medical-payment insurance, insurance under which
benefits are payable with or without regard to fault and that is statutorily
required to be contained in any liability insurance policy or equivalent
self-insurance, student health insurance offered by a Kentucky-licensed insurer
under written contract with a university or college whose students it proposes
to insure, medical expense reimbursement policies specifically designed to fill
gaps in primary coverage, coinsurance, or deductibles and provided under a
separate policy, certificate, or contract, or coverage supplemental to the
coverage provided under Chapter 55 of Title 10, United States Code; or limited
health service benefit plans; and for purposes of KRS 304.17A-600 to
304.17A-633 includes short-term coverage policies;
(7) "Independent review entity" means an individual or organization certified by the
(8)
(9)
(10)
(11)
(12)
(13)
(14)
(15)
(16)
(17)
department to perform external reviews under KRS 304.17A-623,
304.17A-625, and 304.17A-627;
"Insurer" means any of the following entities authorized to issue health benefit
plans as defined in subsection (6) of this section: an insurance company,
health maintenance organization; self-insurer or multiple employer welfare
arrangement not exempt from state regulation by ERISA; provider-sponsored
integrated health delivery network; self-insured employer-organized
association; nonprofit hospital, medical-surgical, or health service corporation;
or any other entity authorized to transact health insurance business in
Kentucky;
"Internal appeals process" means a formal process, as set forth in KRS
304.17A-617, established and maintained by the insurer, its designee, or agent
whereby the covered person, an authorized person, or a provider may contest
an adverse determination rendered by the insurer, its designee, or private
review agent;
"Nationally recognized accreditation organization" means a private nonprofit
entity that sets national utilization review and internal appeal standards and
conducts review of insurers, agents, or independent review entities for the
purpose of accreditation or certification. Nationally recognized accreditation
organizations shall include the National Committee for Quality Assurance
(NCQA), the American Accreditation Health Care Commission (URAC), the
Joint Commission on Accreditation of Healthcare Organizations (JCAHO), or
any other organization identified by the department;
"Private review agent" or "agent" means a person or entity performing
utilization review that is either affiliated with, under contract with, or acting on
behalf of any insurer or other person providing or administering health benefits
to citizens of this Commonwealth. "Private review agent" or "agent" does not
include an independent review entity which performs external review of
adverse determinations;
"Prospective review" means utilization review that is conducted prior to a
hospital admission or a course of treatment;
"Provider" shall have the same meaning as set forth in KRS 304.17A-005;
"Qualified personnel" means licensed physician, registered nurse, licensed
practical nurse, medical records technician, or other licensed medical
personnel who through training and experience shall render consistent
decisions based on the review criteria;
"Registration" means an authorization issued by the department to an insurer
or a private review agent to conduct utilization review;
"Retrospective review" means utilization review that is conducted after health
care services have been provided to a covered person. "Retrospective review"
does not include the review of a claim that is limited to an evaluation of
reimbursement levels, or adjudication of payment;
(a) "Urgent care" means health care or treatment with respect to which the
application of the time periods for making nonurgent determination:
1.
Could seriously jeopardize the life or health of the covered person or
the ability of the covered person to regain maximum function; or
2.
In the opinion of a physician with knowledge of the covered
persons medical condition, would subject the covered person to
severe pain that cannot be adequately managed without the care or
treatment that is the subject of the utilization review; and
(b) "Urgent care" shall include all requests for hospitalization and outpatient
surgery;
(18) "Utilization review" means a review of the medical necessity and
appropriateness of hospital resources and medical services given or proposed
to be given to a covered person for purposes of determining the availability of
payment. Areas of review include concurrent, prospective, and retrospective
review; and
(19) "Utilization review plan" means a description of the procedures governing
utilization review activities performed by an insurer or a private review agent.
Effective:July 15, 2010
History: Amended 2010 Ky. Acts ch. 24, sec. 1235, effective July 15, 2010. -Amended 2004 Ky. Acts ch. 59, sec. 11, effective July 13, 2004. -- Amended
2002 Ky. Acts ch. 181, sec. 4, effective July 15, 2002. -- Created 2000 Ky. Acts
ch. 262, sec. 1, effective July 14, 2000.
Disclaimer: These codes may not be the most recent version. Kentucky may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.