2014 Kentucky Revised Statutes CHAPTER 304 - INSURANCE CODE Subtitle 17A - Health Benefit Plans 17A.17A-607 Duties of insurer or private review agent performing utilization reviews -- Requirement for registration -- Consequences of insurer's failure to make timely utilization review determination -- Requirement that insurer or private review agent submit changes to the department -- Requirement that private review agent provide timely notice of entities for whom it is providing review.
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304.17A-607 Duties of insurer or private review agent performing utilization
reviews -- Requirement for registration -- Consequences of insurer's
failure to make timely utilization review determination -- Requirement that
insurer or private review agent submit changes to the department -Requirement that private review agent provide timely notice of entities for
whom it is providing review.
(1)
An insurer or private review agent shall not provide or perform utilization
reviews without being registered with the department. A registered insurer or
private review agent shall:
(a) Have available the services of sufficient numbers of registered nurses,
medical records technicians, or similarly qualified persons supported by
licensed physicians with access to consultation with other appropriate
physicians to carry out its utilization review activities;
(b) Ensure that only licensed physicians shall:
1.
Make a utilization review decision to deny, reduce, limit, or terminate
a health care benefit or to deny, or reduce payment for a health care
service because that service is not medically necessary,
experimental, or investigational except in the case of a health care
service rendered by a chiropractor or optometrist where the denial
shall be made respectively by a chiropractor or optometrist duly
licensed in Kentucky; and
2.
Supervise qualified personnel conducting case reviews;
(c) Have available the services of sufficient numbers of practicing physicians
in appropriate specialty areas to assure the adequate review of medical
and surgical specialty and subspecialty cases;
(d) Not disclose or publish individual medical records or any other
confidential medical information in the performance of utilization review
activities except as provided in the Health Insurance Portability and
Accountability Act, Subtitle F, secs. 261 to 264 and 45 C.F.R. secs. 160 to
164 and other applicable laws and administrative regulations;
(e) Provide a toll free telephone line for covered persons, authorized
persons, and providers to contact the insurer or private review agent and
be accessible to covered persons, authorized persons, and providers for
forty (40) hours a week during normal business hours in this state;
(f) Where an insurer, its agent, or private review agent provides or performs
utilization review, be available to conduct utilization review during normal
business hours and extended hours in this state on Monday and Friday
through 6:00 p.m., including federal holidays;
(g) Provide decisions to covered persons, authorized persons, and all
providers on appeals of adverse determinations and coverage denials of
the insurer or private review agent, in accordance with this section and
administrative regulations promulgated in accordance with KRS
304.17A-609;
(h) Except for retrospective review of an emergency admission where the
covered person remains hospitalized at the time the review request is
made, which shall be considered a concurrent review, provide a utilization
(2)
(3)
review decision relating to urgent and nonurgent care in accordance with
29 C.F.R. Part 2560, including the timeframes and written notice of the
decision. A written notice in electronic format, including e-mail or
facsimile, may suffice for this purpose where the covered person,
authorized person, or provider has agreed in advance in writing to receive
such notices electronically and shall include the required elements of
subsection (j) of this section;
(i) Provide a utilization review decision within twenty-four (24) hours of
receipt of a request for review of a covered person's continued hospital
stay and prior to the time when a previous authorization for hospital care
will expire;
(j) Provide written notice of review decisions to the covered person,
authorized person, and providers. An insurer or agent that denies
coverage or reduces payment for a treatment, procedure, drug that
requires prior approval, or device shall include in the written notice:
1.
A statement of the specific medical and scientific reasons for denial
or reduction of payment or identifying that provision of the schedule
of benefits or exclusions that demonstrates that coverage is not
available;
2.
The state of licensure, medical license number, and the title of the
reviewer making the decision;
3.
Except for retrospective review, a description of alternative benefits,
services, or supplies covered by the health benefit plan, if any; and
4.
Instructions for initiating or complying with the insurer's internal
appeal procedure, as set forth in KRS 304.17A-617, stating, at a
minimum, whether the appeal shall be in writing, and any specific
filing procedures, including any applicable time limitations or
schedules, and the position and phone number of a contact person
who can provide additional information;
(k) Afford participating physicians an opportunity to review and comment on
all medical and surgical and emergency room protocols, respectively, of
the insurer and afford other participating providers an opportunity to
review and comment on all of the insurer's protocols that are within the
provider's legally authorized scope of practice; and
(l) Comply with its own policies and procedures on file with the department
or, if accredited or certified by a nationally recognized accrediting entity,
comply with the utilization review standards of that accrediting entity
where they are comparable and do not conflict with state law.
The insurer's failure to make a determination and provide written notice within
the time frames set forth in this section shall be deemed to be an adverse
determination by the insurer for the purpose of initiating an internal appeal as
set forth in KRS 304.17A-617. This provision shall not apply where the failure
to make the determination or provide the notice results from circumstances
which are documented to be beyond the insurer's control.
An insurer or private review agent shall submit a copy of any changes to its
utilization review policies or procedures to the department. No change to
(4)
policies and procedures shall be effective or used until after it has been filed
with and approved by the commissioner.
A private review agent shall provide to the department the names of the
entities for which the private review agent is performing utilization review in this
state. Notice shall be provided within thirty (30) days of any change.
Effective:July 15, 2010
History: Amended 2010 Ky. Acts ch. 24, sec. 1236, effective July 15, 2010. -Amended 2004 Ky. Acts ch. 59, sec. 12, effective July 13, 2004. -- Amended
2002 Ky. Acts ch. 181, sec. 5, effective July 15, 2002. -- Amended 2001 Ky.
Acts ch. 145, sec. 2, effective June 21, 2001. -- Created 2000 Ky. Acts ch. 262,
sec. 4, effective July 14, 2000.
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