KRS 304.17A-600: Definitions for KRS 304.17A-600 to 304.17A-633.

As used in KRS 304.17A-600 to 304.17A-633:

(1) "Adverse benefit determination":

(a) Has the same meaning as in 29 C.F.R. sec. 2560.503-1, as amended; and

(b) Includes:

1. A determina tion by an insurer or its designee that the health care

services furnished or proposed to be furnished to a covered person are:

a. Not medically necessary, as determined by the insurer or its

designee; or

b. Experimental or investigational, as determined by the insurer or its

designee; and

2. A coverage denial;

(2) "Authorized person" means a pa rent, guardian, or other person authorized to act on

behalf of a covered person with respect to health care decisions;

(3) "Concurrent review" means utilization review conducted during a covered person's

course of treatment or hospital stay;

(4) "Coverage denial" means a determination that a service, procedure, treatment, drug,

supply, or device is specifically limited or excluded under a covered person's health

benefit plan;

(5) "Covered person" means a person covered under a health benefit plan;

(6) "External review" means a review that is conducted by an independent review

entity which meets specified criteria as established in KRS 304.17A -621, 304.17A-

623, 304.17A-625, and 304.17A-627;

(7) "Health benefit plan" has the same meaning as in KRS 304.17A-005, except that for

purposes of KRS 304.17A -600 to 304.17A -633, the term includes short -term

coverage policies;

(8) "Independent review entity" means an individual or organization certified by the

department to perform external reviews under KRS 304.17A -621, 304.17A-623,

304.17A-625, and 304.17A-627;

(9) "Insurer" means any of the following entities that issue or provide health benefit

plans:

(a) An insurance company;

(b) Health maintenance organization;

(c) Self-insurer or multiple employer welfare arrangemen t not exempt from state

regulation by ERISA;

(d) Provider-sponsored integrated health delivery network;

(e) Self-insured employer-organized association;

(f) Nonprofit hospital, medical-surgical, or health service corporation; or

(g) Any other entity authorized to transact health insurance business in Kentucky;

(10) "Internal appeals process" means a formal appeals process, as set forth in KRS

304.17A-617, established and maintained by the insurer, its designee, or private

review agent;

(11) "Nationally recognized accreditation organization":

(a) Means a private nonprofit entity that:

1. Sets national utilization review and internal appeal standards; and

2. Conducts review of insurers, agents, or independent review entities for

the purpose of accreditation or certification; and

(b) Shall include the Accreditation Association for Ambulatory Health Care

(AAAHC), the National Committee for Quality Assurance (NCQA), the

American Accreditation Health Care Commission (URAC), the Joint

Commission, or any other organization identified by the department;

(12) "Private review agent" or "agent":

(a) Means a person or entity performing utilization review that is either affiliated

with, under contract with, or acting on behalf of any insurer or other person

providing or ad ministering health benefits to citizens of this Commonwealth;

and

(b) Does not include an independent review entity that performs external reviews;

(13) "Prospective review":

(a) Means a utilization review that is conducted prior to the provision of health

care services; and

(b) Includes any insurer's or agent's requirement that a covered person or provider

notify the insurer or agent prior to providing a health care service, inclu ding

but not limited to prior authorization, step therapy protocol, preadmission

review, pretreatment review, utilization, and case management;

(14) "Qualified personnel" means licensed physician, registered nurse, licensed practical

nurse, medical records technician, or other licensed medical personnel who through

training and experience shall render consistent decisions based on the review

criteria;

(15) "Registration" means an authorization issued by the department to an insurer or a

private review agent to conduct utilization review;

(16) "Retrospective review":

(a) Means utilization review that is conducted after health care services have been

provided to a covered person; and

(b) Does not include the review of a claim that is limited to an evaluation o f

reimbursement levels, or adjudication of payment;

(17) "Urgent health care services":

(a) Means health care or treatment with respect to which the application of the

time periods for making a nonurgent determination:

1. Could seriously jeopardize the life or health of the covered person or the

ability of the covered person to regain maximum function; or

2. In the opinion of a physician with knowledge of the covered person's

medical condition, would subject the covered person to severe pain that

cannot be adequately managed without the care or treatment that is the

subject of the utilization review; and

(b) Includes all requests for hospitalization and outpatient surgery;

(18) "Utilization review" means a review of the medical necessity and appropriateness of

hospital resources and medical services given or proposed to be given to a covered

person for purposes of determining the availability of payment. Areas of review

include concurrent, prospective, and retrospective review; and

(19) "Utilization review pl an" means a description of the procedures governing

utilization review activities performed by an insurer or a private review agent.