KRS 304.17A-605: Requirements and procedures for utilization review -- Exception for

private review agent operating under contract with the federal government.

(Effective until January 1, 2028)

(1) KRS 304.17A -600, 304.17A -603, 304.17A -605, 304.17A -607, 304. 17A-609,

304.17A-611, 304.17A -613, and 304.17A -615 set forth the requirements and

procedures regarding utilization review and shall apply to:

(a) Any insurer or its private review agent that provides or performs utilization

review in connection with a heal th benefit plan or a limited health service

benefit plan; and

(b) Any private review agent that performs utilization review functions on behalf

of any person providing or administering health benefit plans or limited health

service benefit plans.

(2) Where an insurer or its agent provides or performs utilization review, and in all

instances where internal appeals as set forth in KRS 304.17A -617 are involved, the

insurer or its agent shall be responsible for:

(a) Monitoring all utilization reviews and intern al appeals carried out by or on

behalf of the insurer;

(b) Ensuring that all requirements of KRS 304.17A-600 to 304.17A-633 are met;

(c) Ensuring that all administrative regulations promulgated in accordance with

KRS 304.17A-609, 304.17A-613, and 304.17A-629 are complied with; and

(d) Ensuring that appropriate personnel have operational responsibility for the

performance of the insurer's utilization review plan.

(3) A private review agent that operates solely under contract with the federal

government for u tilization review or patients eligible for hospital services under

Title XVIII of the Social Security Act shall not be subject to the registration

requirements set forth in KRS 304.17A-607, 304.17A-609, and 304.17A-613.

Effective: July 15, 2002