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304.17A-627
Certification as independent review entity -- Requirements and
restrictions.
(1)
(2)
(3)
(4)
(5)
(6)
(7)
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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