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304.17A-613 Emergency administrative regulations governing registration of
insurers and private review agents seeking to conduct utilization reviews
-- Procedure for handling complaints.
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
The department shall, through the promulgation of emergency administrative
regulations, develop a process:
(a) For the review of applications for registration of insurers or private review
agents seeking to conduct utilization reviews;
(b) For the review of applications for insurers or private review agents
seeking registration renewal to continue as a utilization review entity;
(c) Ensuring that no registration shall be approved unless the commissioner
has documentation or findings that all applicants seeking registration or
renewal to conduct utilization review are in compliance with the
requirements and procedures established regarding utilization review, and
as to renewals, have complied with KRS 304.17A-600 to 304.17A-633
and administrative regulations promulgated to enforce and to administer
KRS 304.17A-600 to 304.17A-633; and
(d) Establishing fees for applications and renewals in an amount sufficient to
pay the administrative costs of the program and any other costs
associated with carrying out the provisions of KRS 304.17A-600,
304.17A-603, 304.17A-605, 304.17A-607, 304.17A-609, 304.17A-611,
304.17A-613, and 304.17A-615.
The registration issued in accordance with this section expires on the second
anniversary of the effective date unless it is renewed.
The registration issued under this section is not transferable.
The commissioner may revoke or suspend the utilization review registration of
any insurer or private review agent who does not comply with the requirements
and procedures established regarding utilization review or any administrative
regulations promulgated thereunder.
The department shall establish reporting requirements to:
(a) Evaluate the effectiveness of insurers and private review agents; and
(b) Determine if the utilization review plans are in compliance with the
requirements and procedures established regarding utilization review and
applicable administrative regulations.
Upon request of any provider, authorized person, or covered person whose
care is subject to review, the department shall provide copies of policies or
procedures of any insurer or private review agent that has been issued a
registration by the department to conduct review in this state.
Notwithstanding any provision to the contrary, an insurer or private review
agent registered and in good standing under the provisions of KRS 211.461 to
211.466, prior to July 14, 2000, shall be deemed in compliance with
requirements and procedures established in KRS 304.17A-600 to 304.17A-633
regarding utilization review and registered accordingly.
Upon receipt of written complaints from covered persons, authorized persons,
or providers stating that an insurer or a private review agent has failed to
perform a review in accordance with the utilization review plan or the
requirements and procedures established regarding utilization review, or
administrative regulations promulgated thereunder, the commissioner shall:
(a) Send a copy of the complaint to the insurer or the private review agent
within ten (10) days of receipt of the complaint, and require that any
written reply be sent to the commissioner within ten (10) days; and
(b) Review the complaint and any written reply received from the insurer or
private review agent within the time frames set forth in paragraph (a) of
this subsection and make a recommendation to the insurer or private
review agent and the covered person, authorized person, or provider.
(9) The commissioner shall consider complaints before issuing or renewing any
registration or renewal of a registration to an insurer or a private review agent.
(10) Notwithstanding any provision in this section to the contrary, the department
shall accept accreditation or certification by a nationally recognized
accreditation organization as sufficient documentation or finding for purposes
of subsections (1) and (5) of this section that the insurer or private review agent
meets the application requirements for registration or renewal. Insurers or
private review agents accredited or certified by a nationally recognized
accreditation organization shall be deemed compliant with the utilization review
and internal appeals requirements of this section and KRS 304.17A-600,
304.17A-607, 304.17A-609, 304.17A-617, 304.17A-623, and 304.17A-625 and
administrative regulations to the extent the standards of such nationally
recognized accreditation organization sufficiently meet these requirements.
The department shall have a simplified process in administrative regulations for
insurers and private review agents to register using accreditation or certification
and shall limit any additional documentation only for demonstrating compliance
with requirements in this section and KRS 304.17A-600, 304.17A-607,
304.17A-609, 304.17A-617, 304.17A-623, and 304.17A-625 not met by the
standards of a nationally recognized accreditation organization.
Effective:July 15, 2010
History: Amended 2010 Ky. Acts ch. 24, sec. 1238, effective July 15, 2010. -Amended 2002 Ky. Acts ch. 181, sec. 7, effective July 15, 2002. -- Created 2000
Ky. Acts ch. 262, sec. 7, effective July 14, 2000.
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