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304.17A-609 Emergency administrative regulations governing utilization review
and internal appeal to be promulgated by the department.
The department shall promulgate emergency administrative regulations regarding
utilization review and internal appeal, including the specification of information required
of insurers and private review agents which shall, at a minimum, include:
(1) A utilization review plan that contains all information utilized for conducting
preadmission, admission, readmission review, preauthorization, continued stay
authorization, and retrospective review and which, for each type of review,
includes:
(a) Utilization review policies and procedures to evaluate proposed or delivered
medical services;
(b) Time frames for review;
(c) A written summary describing the review process and required forms;
(d) Documentation that actively practicing providers with appropriate
qualifications are involved in the development or adoption of utilization
review criteria relating to specialty and subspecialty areas;
(e) Descriptions and names of review criteria upon which utilization review
decisions are based; and
(f) Additional standards, if any, for the consideration of special circumstances;
(2) The type and qualifications of the personnel either employed or under contract to
perform utilization review;
(3) Assurance that a toll-free line will be provided that covered persons, authorized
persons, and providers may use to contact the insurer or private review agent;
(4) The policies and procedures to ensure that a representative of the insurer or private
review agent shall be reasonably accessible to covered persons, authorized persons,
and providers at least forty (40) hours per week during normal business hours;
(5) The policies and procedures to ensure that all applicable state and federal laws to
protect the confidentiality of individual medical records are followed;
(6) A copy of the materials designed to inform covered persons, authorized persons,
and providers of the toll-free number and the requirements of the utilization review
plan;
(7) A list of the entities for which the private review agent is performing utilization
review in this state; and
(8) Evidence of compliance or the ability to comply with the requirements and
procedures established regarding utilization review and the administrative
regulations promulgated thereunder.
(9) In lieu of disclosing information specified in subsection (1) of this section, an
insurer or private review agent may submit to the department evidence of
accreditation or certification, if any, with a nationally recognized accreditation
organization that oversees the information described in subsections (1) to (8) of this
section, provided that the department may still require the information in subsection
(8) of this section or other information to demonstrate compliance with the
requirements of this section and KRS 304.17A-600, 304.17A-607, 304.17A-613,
304.17A-617, 304.17A-623, and 304.17A-625 not covered by the standards of the
nationally recognized accreditation organization, as well as basic information
necessary for the department to contact the insurer or private review agent. Nothing
in this subsection shall be construed to prohibit or in any way limit the department's
authority to require the submission of information specified in subsections (1) to (8)
of this section or any other information the department deems necessary for
purposes of investigating a complaint that the insurer or private review agent is not
in compliance with KRS 304.17A-600 to 304.17A-633.
Effective: July 15, 2010
History: Amended 2010 Ky. Acts ch. 24, sec. 1237, effective July 15, 2010. -Amended 2002 Ky. Acts ch. 181, sec. 6, effective July 15, 2002. -- Created 2000 Ky.
Acts ch. 262, sec. 5, effective July 14, 2000.
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