KRS 205.6315: Requirements when private peer review organization is contracted with

to conduct reviews of levels of care.

When the cabinet contracts with any private peer review organization to conduct

utilization reviews of the levels of care of the state's Medic aid program recipients, the

following shall apply:

(1) In determining the appropriate level of care of a Medicaid beneficiary who is a

patient in a nursing facility setting, and prior to any change that reduces a Medicaid

beneficiary's eligibility for covered services, the contracted peer review organization

shall assure that:

(a) An in-person assessment of the Medicaid beneficiary is made; and

(b) A licensed physician has reviewed the written documentation of the peer

review organization's evaluation and p rovided a written review of the

evaluation to be a part of the patient's record.

(2) If the level of care is changed for a Medicaid beneficiary who is a resident or patient

in a nursing facility setting or a Medicaid beneficiary who receives community -

based waiver services, and the change makes that beneficiary ineligible for the

Medicaid covered service, the peer review organization shall notify the

commissioner of Medicaid in the cabinet, and shall provide a written notification

sent by registered return receipt mail to the affected Medicaid beneficiary, nursing

facility, affected Medicaid beneficiary's attending physician, and the affected

beneficiary's responsible party.

(3) If the level of care for a Medicaid beneficiary results in an adverse determinat ion,

the affected Medicaid beneficiary, or the responsible person or party, may appeal

through an application for reconsideration to be filed with the cabinet within ten

(10) days from the date of receipt of the registered return receipt written

notification. If the responsible party's registered return receipt mail is undeliverable,

the attending physician may initiate the appeal on behalf of the affected Medicaid

beneficiary.

(a) All benefits which the affected Medicaid recipient, and the nursing facility are

eligible for shall be continued during that ten (10) day time frame; and

(b) As long as the affected Medicaid recipient is engaged in an appeal of an

adverse determination from a peer review organization, all benefits for which

the affected Medicaid r ecipient and nursing facility are eligible shall be

continued until an appropriate residential setting is secured, in any event, not

to exceed ninety (90) days from the date of the request for a hearing, or until a

final determination is made by a hearing officer.

(4) (a) If the level of care is lowered for a Medicaid beneficiary who is a resident or

patient in a nursing facility setting, an independent examination may be

conducted by the resident's attending physician.

(b) If the resident's attending physician conducts an independent examination, the

attending physician shall make a recommendation concerning the appropriate

level of care and forward, in writing, the results of the examination and the

recommendation to the peer review organization, the affec ted recipient, the

nursing facility, and the responsible party.

(5) For the purposes of this section, "responsible person or party" shall mean an

individual authorized by the resident of the facility to act for the resident as an

official delegate or agent. The responsible person may be a guardian, payee, family

member, or any other individual who has arranged for the care of the resident and

assumed this responsibility. The responsible party may or may not be related to the

resident. A responsible person o r party is not a guardian unless so appointed by the

court.

(6) The peer review organization shall:

(a) Inform the patient and guardian, responsible party, or family member, upon

initial qualification for Medicaid covered services, and with the written

notification of an adverse determination from a peer review organization:

1. Of the manner in which notific ation of any adverse decision will be

made;

2. Of the process for securing a timely review of any adverse decision;

3. That a request for reconsideration must be postmarked no later than ten

(10) days after receipt of the initial written notification of an y adverse

decision;

4. Of the toll -free line that will be provided for questions regarding

reviews; and

5. Of the process for appealing an adverse reconsideration to the cabinet;

(b) Provide a written peer review organization physician review of all advers e

determinations;

(c) Provide for an attending physician review of all adverse determinations as

outlined in subsection (4) of this section;

(d) Inform the commissioner of all information related to an appeal of an adverse

action; and

(e) Provide the infor mation identified in paragraph (a) of this subsection, at the

time of an adverse determination notification, to any affected nursing facility

in which a Medicaid beneficiary resides.