2014 Kentucky Revised Statutes CHAPTER 304 - INSURANCE CODE Subtitle 17A - Health Benefit Plans 17A.17A-625 Factors to be considered by independent review entity conducting external review -- Basis for decision -- Insurer's responsibilities -- Contents, admissibility, and effect of decision -- Consequence of insurer's failure to provide coverage -- Liability -- Written complaints.
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304.17A-625 Factors to be considered by independent review entity
conducting external review -- Basis for decision -- Insurer's
responsibilities -- Contents, admissibility, and effect of decision -Consequence of insurer's failure to provide coverage -- Liability -- Written
complaints.
(1)
(2)
(3)
(4)
(5)
(6)
In making its decision, an independent review entity conducting the external
review shall take into account all of the following:
(a) Information submitted by the insurer, the covered person, the authorized
person, and the covered person's provider, including the following:
1.
The covered person's medical records;
2.
The standards, criteria, and clinical rationale used by the insurer to
make its decision; and
3.
The insurer's health benefit plan;
(b) Findings, studies, research, and other relevant documents of government
agencies and nationally recognized organizations, including the National
Institutes of Health, or any board recognized by the National Institutes of
Health, the National Cancer Institute, the National Academy of Sciences,
and the United States Food and Drug Administration, the Centers for
Medicare & Medicaid Services of the United States Department of Health
and Human Services, and the Agency for Health Care Research and
Quality; and
(c) Relevant findings in peer-reviewed medical or scientific literature,
published opinions of nationally recognized medical specialists, and
clinical guidelines adopted by relevant national medical societies.
The independent review entity shall base its decision on the information
submitted under subsection (1) of this section. In making its decision, the
independent review entity shall consider safety, appropriateness, and cost
effectiveness.
The insurer shall provide any coverage determined by the independent review
entity to be medically necessary. The independent review entity shall not be
permitted to allow coverage for services specifically limited or excluded by the
insurer in its health benefit plan. The decision shall apply only to the individual
covered person's external review.
Nothing in this section shall be construed as requiring an insurer to provide
coverage for out of network services, procedures, or tests, except as set forth
in KRS 304.17A-515(1)(c) and 304.17A-550.
The insurer shall be responsible for the cost of the external review.
The independent review entity shall provide to the covered person, treating
provider, insurer, and the department a decision which shall include:
(a) The findings for either the insurer or covered person regarding each issue
under review;
(b) The proposed service, treatment, drug, device, or supply for which the
review was performed;
(c) The relevant provisions in the insurer's health benefit plan and how
applied; and
(d)
(7)
(8)
(9)
(10)
(11)
(12)
(13)
(14)
(15)
The relevant provisions of any nationally recognized and peer-reviewed
medical or scientific documents used in the external review.
The decision of the independent review entity shall not be made solely for the
convenience of the insurer, the covered person, or the provider.
Consistent with the rules of evidence, a written decision prepared by an
independent review entity shall be admissible in any civil action related to the
adverse determination. The independent review entity's decision shall be
presumed to be a scientifically valid and accurate description of the state of
medical knowledge at the time it was written.
The decision of the independent review entity shall be binding on the insurer
with respect to that covered person. Failure of the insurer to provide coverage
as required by the independent review entity shall:
(a) Be a violation of the insurance code of a nature sufficient to warrant the
commissioner revoking or suspending the insurer's license or certificate of
authority; and
(b) Constitute an unfair claims settlement practice as set forth in KRS
304.12-230.
Failure to provide coverage as required by the independent review entity shall
also subject the insurer to the provisions of KRS 304.99-010 and 304.99-020
and require the insurer to pay the claim that was the subject of the external
review, without need for the covered person or authorized person to further
establish a right as to the payment amount. Reasonable attorney fees
associated with the actions of the insured necessary to collect amounts owed
the covered person shall be assessed against and borne by the insurer.
The insurer shall implement the decision of the independent review entity
whether the covered person has disenrolled or remains enrolled with the
insurer.
If the covered person has been disenrolled with the insurer, the insurer shall
only be required to provide the treatment, service, drug, or device that was
previously denied by the insurer, its agent, or designee and later approved by
the independent review entity for a period not to exceed thirty (30) days.
Within thirty (30) days of the decision in favor of the covered person by the
independent review entity, the insurer shall provide written notification to the
department that the decision has been implemented in accordance with this
section.
An independent review entity and any medical specialist the entity utilizes in
conducting an external review shall not be liable in damages in a civil action for
injury, death, or loss to person or property and is not subject to professional
disciplinary action for making, in good faith, any finding, conclusion, or
determination required to complete the external review. This subsection does
not grant immunity from civil liability or professional disciplinary action to an
independent review entity or medical specialist for an action that is outside the
scope of authority granted in KRS 304.17A-621, 304.17A-623, and
304.17A-625.
Nothing in KRS 304.17A-600 to 304.17A-633 shall be construed to create a
cause of action against any of the following:
(a)
An employer that provides health care benefits to employees through a
health benefit plan;
(b) A medical expert, private review agent, or independent review entity that
participates in the utilization review, internal appeal, or external review
addressed in KRS 304.17A-600 to 304.17A-633; or
(c) An insurer or provider acting in good faith and in accordance with any
finding, conclusion, or determination of an Independent Review Entity
acting within the scope of authority set forth in KRS 304.17A-621,
304.17A-623, and 304.17A-625.
(16) The covered person, insurer, or provider in the external review may submit
written complaints to the department regarding any independent review entity's
actions believed to be an inappropriate application of the requirements set forth
in KRS 304.17A-621, 304.17A-623, and 304.17A-625. The department shall
promptly review the complaint, and if the department determines that the
actions of the independent review entity were inappropriate, the department
shall take corrective measures, including decertification or suspension of the
independent review entity from further participation in external reviews. The
department's actions shall be subject to the powers and administrative
procedures set forth in Subtitle 17A of KRS Chapter 304.
Effective:July 15, 2010
History: Amended 2010 Ky. Acts ch. 24, sec. 1242, effective July 15, 2010. -Amended 2002 Ky. Acts ch. 181, sec. 10, effective July 15, 2002. -- Created
2000 Ky. Acts ch. 262, sec. 13, effective July 14, 2000.
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