KRS 304.17A-545: Medical director for managed care plan -- Duties -- Quality assurance

or improvement standards -- Process to select health care providers -- Uniform

application form and guidelines for health care provider evaluations.

(1) A managed care plan shall appoint a medical director who:

(a) Is a physician licensed to practice in this state;

(b) Is in good standing with the State Board of Medical Licensure;

(c) Has not had his or her license revoked or suspended under KRS 311.530 to

311.620; and

(d) Shall be responsible for the treatment policies, protocols, quality assurance

activities, and utilization management decisions of the plan.

(2) The medical director shall ensure that:

(a) Any utilization management decision to deny, reduce, or terminate a health

care benefit or to deny payment for a health care service because that service

is not medically necessary shall be made by a physician, except in the case of

a health care service rendered by a chiropractor or optometrist, that decision

shall be made respectively by a chiropractor or optometrist duly licensed in

Kentucky;

(b) A utilization management decision shall not retrospectively deny coverage for

health care services provided to a covered person when prior approval has

been obtained from the insurer for those services, unless the approval was

based upon fraudulent, materially inaccurate, or misrepresented information

submitted by the covered person or the participating provider;

(c) In the case of a managed care plan, a procedure is implemented whereby:

1. Participating physicians have an opportunity to review and comment on

all medical and surgical and emergency room protocols, respectively, of

the insurer; and

2. Other participating providers have an opportunity to review and

comment on all of the insurer's protocols that are within the provider's

legally authorized scope of practice;

(d) The utilization management program is available to respond to authorization

requests for urgent services and is available, at a minimum, during normal

working hours for inquiries and authorization requests for nonurgent health

care services; and

(e) In the case of a managed care plan, a covered person is permitted to choose or

change a primary care provider from among participating providers in the

provider network and, when appropriate, choose a specialist from among

participating network providers following an authorized referral, if required

by the insurer, and subject to the abi lity of the specialist to accept new

patients.

(3) A managed care plan shall develop comprehensive quality assurance or

improvement standards adequate to identify, evaluate, and remedy problems

relating to access, continuity, and quality of health care ser vices. These standards

shall be made available to the public during regular business hours and include:

(a) An ongoing written, internal quality assurance or improvement program;

(b) Specific written guidelines for quality of care studies and monitoring,

including attention to vulnerable populations;

(c) Performance and clinical outcomes-based criteria;

(d) A procedure for remedial action to correct quality problems, including written

procedures for taking appropriate corrective action;

(e) A plan for data gathering and assessment; and

(f) A peer review process.

(4) Each managed care plan shall have a process for the selection of health care

providers who will be on the plan's list of participating providers, with written

policies and procedures for review and approval used by the plan.

(a) The plan shall establish minimum professional requirements for participating

health care providers. An insurer may not discriminate against a provider

solely on the basis of the provider's license by the state;

(b) The plan shall demonstrate that it has consulted with appropriately qualified

health care providers to establish the minimum professional requirements;

(c) The plan's selection process shall include verification of each health care

provider's license, history of license suspension or revocation, and liability

claims history;

(d) A managed care plan shall establish a formal written, ongoing process for the

reevaluation of each participating health care provider within a specified

number of years after the provider' s initial acceptance into the plan. The

reevaluation shall include an update of the previous review criteria and an

assessment of the provider's performance pattern based on criteria such as

enrollee clinical outcomes, number of complaints, and malpractice actions.

(5) The commissioner shall promulgate administrative regulations to establish a

uniform application form and guidelines for the evaluation and reevaluation of

health care providers, including psychologists, who will be on the plan's list of

participating providers in accordance with subsection (4) of this section. In

developing a uniform application and guidelines, the department shall consider

industry standards and guidelines adopted by the Council for Affordable Quality

Healthcare. The uniform application form and guidelines shall be used by all

insurers.

(6) A managed care plan shall not use a health care provider beyond, or outside of, the

provider's legally authorized scope of practice.