KRS 304.17A-525: Standards for provider participation -- Mechanisms for consideration

of provider applications -- Policy for removal or withdrawal.

(1) Insurers shall establish relevant, objective standards for initial consideration of

providers and for providers to continue as a participating provider in the plan.

Standards shall be reasonably related to services provided. Selection or participation

standards based on the economics or capacity of a provider's practice shall be

adjusted to account for case mix, sev erity of illness, patient age and other features

that may account for higher-than- or lower-than-expected costs. All data profiling or

other data analysis pertaining to participating providers shall be done in a manner

which is valid and reasonable. Plans shall not use criteria that would allow an

insurer to avoid high -risk populations by excluding providers because they are

located in geographic areas that contain populations or providers presenting a risk

of higher -than-average claims, losses, or health s ervices utilization or that would

exclude providers because they treat or specialize in treating populations presenting

a risk of higher-than-average claims, losses, or health services utilization.

(2) Each insurer shall establish mechanisms for soliciting and acting upon applications

for provider participation in the plan in a fair and systematic manner. These

mechanisms shall, at a minimum, include:

(a) Allowing all providers who desire to apply for participation in the plan an

opportunity to apply at any time during the year or, where an insurer does not

conduct open continuous provider enrollment, conducting a provider

enrollment period at least annually with the date publicized to providers

located in the geographic service area of the plan at least thi rty (30) days in

advance of the enrollment periods; and

(b) Making criteria for provider participation in the plan available to all

applicants.

(3) If a managed care plan terminates the participation of an enrollee's primary care

provider, the plan shall p rovide notice to the enrollee and arrange for the enrollee's

continuity of care with an approved primary care provider.

(4) An insurer that offers a managed care plan shall establish a policy governing the

removal of and withdrawal by health care providers from the provider network that

includes the following:

(a) The insurer shall inform a participating health care provider of the insurer's

removal and withdrawal policy at the time the insurer contracts with the health

care provider to participate in the p rovider network, and when changed

thereafter;

(b) If a participating health care provider's participation will be terminated or

withdrawn prior to the date of the termination of the contract as a result of a

professional review action, the insurer and part icipating health care provider

shall comply with the standards in 42 U.S.C. sec. 11112; and

(c) If the insurer finds that a health care provider represents an imminent danger

to an individual patient or to the public health, safety, or welfare, the medical

director shall promptly notify the appropriate professional state licensing

board.