2014 Kentucky Revised Statutes CHAPTER 304 - INSURANCE CODE Subtitle 17A - Health Benefit Plans 17A.17A-716 Prohibition against denial or reduction of payment for covered health benefit -- Conditions.
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304.17A-716 Prohibition against denial or reduction of payment for covered
health benefit -- Conditions.
(1)
(2)
(3)
(4)
(5)
No insurer or any other person providing or administering a health benefit plan
shall deny or reduce payment for a service, procedure, treatment, drug, or
device covered under the covered person's health benefit plan if:
(a) The covered person's provider, during normal business hours, contacts
the insurer or the insurer's designee or agent on the day the covered
person is expected to be discharged to request review of the covered
person's continued hospitalization and the insurer, designee, or agent
fails to provide a utilization review decision within twenty-four (24) hours
of the request and prior to the time upon which any previous authorization
will expire; or
(b) 1.
The covered person's provider makes at least three (3) documented
attempts during a four (4) consecutive hour period to contact the
insurer, designee, or agent during normal business hours to request:
a.
Review of a continued hospital stay;
b.
Preauthorization of treatment for a covered person who is
already hospitalized; or
c.
Retrospective review of an emergency hospital admission
where the covered person remains hospitalized at the time the
review requested is made; and
2.
The insurer, designee, or private review agent fails to be accessible
via a toll-free telephone line for forty (40) hours per week during
normal business hours.
The insurer's liability to pay for the covered person's hospitalization under the
circumstances set forth in subsection (1) of this section shall extend until the
insurer, designee, or private review agent issues a utilization review decision
on a request for review of the matters addressed under subsection (1)(b) of this
section.
The insurer's liability to pay under this section shall be conditioned on:
(a) The provider establishing verifiable documentation of the contact with,
and subsequent failure of the insurer, designee, or agent to make the
utilization review decision as set forth in subsection (1)(a) of this section;
or
(b) The provider establishing verifiable documentation of the attempt to make
contact with the insurer, designee, or agent as addressed in subsection
(1)(b) of this section.
In either instance, the contact or attempts to contact, as set forth in this
section, shall be made by the means required by the insurer, designee, or
agent for requesting utilization review.
This section applies only when the request for review concerns covered health
benefits, and it shall not supersede any limitations or exclusions in the covered
person's health benefit plan. This section shall not apply if, in requesting a
review, the provider does not furnish the information requested by the insurer
or agent to make a utilization review decision or if actions by the provider
impede an insurer's or private review agent's ability to issue a utilization review
decision.
Effective:July 14, 2000
History: Created 2000 Ky. Acts ch. 436, sec. 9, effective July 14, 2000.
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