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304.17A-627 Certification as independent review entity -- Requirements and
restrictions.
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To be certified as an independent review entity under this chapter, an
organization shall submit to the department an application on a form required
by the department. The application shall include the following:
(a) The name of each stockholder or owner of more than five percent (5%) of
any stock or options for an applicant;
(b) The name of any holder of bonds or notes of the applicant that exceeds
one hundred thousand dollars ($100,000);
(c) The name and type of business of each corporation or other organization
that the applicant controls or with which it is affiliated and the nature and
extent of the affiliation or control;
(d) The name and a biographical sketch of each director, officer, and
executive of the applicant and any entity listed under paragraph (c) of this
subsection and a description of any relationship the named individual has
with an insurer as defined in KRS 304.17A-600 or a provider of health
care services;
(e) The percentage of the applicant's revenues that are anticipated to be
derived from independent reviews;
(f) A description of the minimum qualifications employed by the independent
review entity to select health care professionals to perform external
review, their areas of expertise, and the medical credentials of the health
care professionals currently available to perform external reviews; and
(g) The procedures to be used by the independent review entity in making
review determinations.
If at any time there is a material change in the information included in the
application, provided for in subsection (1) of this section, the independent
review entity shall submit updated information to the department.
An independent review entity shall not be a subsidiary of, or in any way
affiliated with, or owned, or controlled by an insurer or a trade or professional
association of payors.
An independent review entity shall not be a subsidiary of, or in any way
affiliated with, or owned, or controlled by a trade or professional association of
providers.
Health care professionals who are acting as reviewers for the independent
review entity shall hold in good standing a nonrestricted license in a state of the
United States.
Health care professionals who are acting as reviewers for the independent
review entity shall hold a current certification by a recognized American
medical specialty board or other recognized health care professional boards in
the area appropriate to the subject of the review, be a specialist in the
treatment of the covered person's medical condition under review, and have
actual clinical experience in that medical condition.
The independent review entity shall have a quality assurance mechanism to
ensure the timeliness and quality of the review, the qualifications and
independence of the physician reviewer, and the confidentiality of medical
records and review material.
(8) Neither the independent review entity nor any reviewers of the entity, shall
have any material, professional, familial, or financial conflict of interest with any
of the following:
(a) The insurer involved in the review;
(b) Any officer, director, or management employee of the insurer;
(c) The provider proposing the service or treatment or any associated
independent practice association;
(d) The institution at which the service or treatment would be provided;
(e) The development or manufacture of the principal drug, device, procedure,
or other therapy proposed for the covered person whose treatment is
under review; or
(f) The covered person.
(9) As used in this section, "conflict of interest" shall not be interpreted to include:
(a) A contract under which an academic medical center or other similar
medical center provides health care services to covered persons, except
for academic medical centers that may provide the service under review;
(b) Provider affiliations which are limited to staff privileges; or
(c) A specialist reviewer's relationship with an insurer as a contracting health
care provider, except for a specialist reviewer proposing to provide the
service under review.
(10) On an annual basis, the independent review entity shall report to the
department the following information:
(a) The number of independent review decisions in favor of covered persons;
(b) The number of independent review decisions in favor of insurers;
(c) The average turnaround time for an independent review decision;
(d) The number of cases in which the independent review entity did not reach
a decision in the time specified in statute or administrative regulation; and
(e) The reasons for any delay.
Effective:July 15, 2010
History: Amended 2010 Ky. Acts ch. 24, sec. 1243, effective July 15, 2010. -Amended 2004 Ky. Acts ch. 59, sec. 15, effective July 13, 2004. -- Created 2000
Ky. Acts ch. 262, sec. 14, effective July 14, 2000.
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