KRS 304.17A-540: Disclosure of limitations on coverage -- Denial letter.

(1) Any insurer that limits coverage for any treatment, procedure, a drug, or device

shall define the limitations and fully disclose those limits in the health insurance

policy or certificate coverage.

(2) (a) Any insurer that denies coverage for a treatment, procedure, a drug that

requires prior approval, or device for an enrollee shall provide the enrollee

with a denial letter that shall include:

1. The state of licensure and title of the person making the decision;

2. A statement setting forth the specific medical and scientific reasons for

denying coverage of a service, if the coverage is denied for reasons of

medical necessity; and

3. Instructions for initiating or complying with the plan's grievance or

appeal procedure stating at a minimum whether the appeal must be in

writing, any time limitations or schedules for filing appeals and the

name and phone number of a contact person who can provide additional

information.

(b) The denial letter shall be provided within:

1. Two (2) regular working days of the submitted request where

preauthorization for a treatment, procedure, drug, or device is involved;

2. Twenty-four (24) hours of the submitted request where hospital

preadmission review is sought;

3. Twenty (20) working days of the receipt of requested medical

information where the plan has initiated a retrospective review; and

4. Twenty (20) working days of the initiation of the review process in all

other instances.