KRS 304.17A-607: Duties of insurer or private review agent performing utilization

reviews -- Requirement for registration -- Consequences of insurer's failure to

make timely utilization review determination -- Requirement that insurer or

private review agent submit changes to the department -- Requirement that

private review agent provide timely notice of entities for whom it is providing

review.

(1) An insurer or private review agent shall not provide or perform utilization reviews

without being registered with the department.

(2) A registered insurer or private review agent shall:

(a) Have available the services of sufficient numbers of registered nurses,

medical records technicians, or similarly qualified persons supported by

licensed physician s with access to consultation with other appropriate

physicians to carry out its utilization review activities;

(b) Ensure that for the provision of utilization review services, only licensed

physicians, who are of the same or similar specialty and subspec ialty, when

possible, as the ordering provider, shall:

1. Make a utilization review decision to:

a. Deny, reduce, limit, or terminate a health care benefit; or

b. Deny, or reduce payment for, a health care service because that

service is not medically nece ssary, experimental, or

investigational;

except in the case of a health care service rendered by a chiropractor or

optometrist where the denial shall be made respectively by a

chiropractor or optometrist duly licensed in Kentucky; and

2. Supervise qualified personnel conducting case reviews;

(c) Have available the services of sufficient numbers of practicing physicians in

appropriate specialty areas to assure the adequate review of medical and

surgical specialty and subspecialty cases;

(d) Not disclose or publish individual medical records or any other confidential

medical information in the performance of utilization review activities except

as provided in the Health Insurance Portability and Accountability Act,

Subtitle F, secs. 261 to 264 and 45 C.F.R. pts. 160 to 164 and other applicable

laws and administrative regulations;

(e) Provide a toll-free telephone line for covered persons, authorized persons, and

providers to contact the insurer or private review agent and be accessible to

covered persons, authorized persons, and providers for forty (40) hours a

week during normal business hours in this state;

(f) Where an insurer, its agent, or private review agent provides or performs

utilization review, be available to conduct utilization rev iew during normal

business hours and extended hours in this state on Monday and Friday through

6:00 p.m., including federal holidays;

(g) Provide decisions to covered persons, authorized persons, and all providers on

appeals of adverse benefit determinatio ns of the insurer or private review

agent, in accordance with this section and administrative regulations

promulgated in accordance with KRS 304.17A-609;

(h) Except for retrospective review of an emergency admission where the covered

person remains hospita lized at the time the review request is made, which

shall be considered a concurrent review, or as otherwise provided in this

subtitle, provide a utilization review decision in accordance with the

timeframes in paragraph (i) of this subsection and 29 C.F.R . pt. 2560,

including written notice of the decision;

(i) 1. Render a utilization review decision concerning urgent health care

services, and notify the covered person, authorized person, or provider

of that decision no later than twenty -four (24) hours af ter obtaining all

necessary information to make the utilization review decision; and

2. If the insurer or agent requires a utilization review decision of nonurgent

health care services, render a utilization review decision and notify the

covered person, au thorized person, or provider of the decision within

five (5) days of obtaining all necessary information to make the

utilization review decision.

For purposes of this paragraph, "necessary information" is limited to:

a. The results of any face-to-face clinical evaluation;

b. Any second opinion that may be required; and

c. Any other information determined by the department to be

necessary to making a utilization review determination;

(j) 1. Provide written notice of review decisions to the covered person,

authorized person, and providers.

2. The written notice may be provided in an electronic format, including

email or facsimile, if the covered person, authorized person, or provider

has agreed in advance in writing to receive the notices electronically.

3. An insurer or agent that denies a step therapy exception, as defined in

KRS 304.17A -163, or denies coverage or reduces payment for a

treatment, procedure, drug that requires prior approval, or device shall

include in the written notice:

a. A statement of th e specific medical and scientific reasons for

denial or reduction of payment or identifying that provision of the

schedule of benefits or exclusions that demonstrates that coverage

is not available;

b. The title of the reviewer making the decision, except that a written

notice provided to a provider shall also include, if applicable, the

medical license number of the reviewer making the decision;

c. Except for retrospective review, a description of alternative

benefits, services, or supplies covered by the health benefit plan, if

any; and

d. Instructions for initiating or complying with the insurer's internal

appeal procedure, as set forth in KRS 304.17A -617, stating, at a

minimum:

i. Whether the appeal shall be in writing;

ii. Any specific filing procedures, including any applicable time

limitations or schedules; and

iii. The position and phone number of a contact person who can

provide additional information;

(k) Afford participating physicians an opportunity to review and comment on all

medical and surgica l and emergency room protocols, respectively, of the

insurer and afford other participating providers an opportunity to review and

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

authorized scope of practice; and

(l) Comply with its own policies and procedures on file with the department or, if

accredited or certified by a nationally recognized accrediting entity, comply

with the utilization review standards of that accrediting entity where they are

comparable and do not conflict with state law.

(3) (a) The insurer's or private review agent's failure to make a determination and

provide written notice within the time frames set forth in this section shall be

deemed to be a prior authorization for the health care services or benefits

subject to the review.

(b) This subsection shall not apply where the failure to make the determination or

provide the notice results from circumstances which are documented to be

beyond the insurer's control.

(4) (a) An insurer or private review agent shall submit a copy of any changes to its

utilization review policies or procedures to the department.

(b) No change to utilization review policies and procedures shall be effective or

used until after it has been filed with and approved by the commissioner.

(5) (a) A private review agent shall provide to the department the names of the

entities for which the private review agent is performing utilization review in

this state.

(b) Notice shall be provided to the department within thirty (30) days of any

change.