KRS 304.17A-609: Emergency administrative regulations governing utilization review

and internal appeal to be promulgated by the department.

The department shall promulgate emergency administrative regulations regarding

utilization review and internal appeal, inclu ding the specification of information required

of insurers and private review agents which shall, at a minimum, include:

(1) A utilization review plan that contains all information utilized for conducting

preadmission, admission, readmission review, preaut horization, continued stay

authorization, and retrospective review and which, for each type of review,

includes:

(a) Utilization review policies and procedures to evaluate proposed or delivered

medical services;

(b) Time frames for review;

(c) A written summary describing the review process and required forms;

(d) Documentation that actively practicing providers with appropriate

qualifications are involved in the development or adoption of utilization

review criteria relating to specialty and subspecialty areas;

(e) Descriptions and names of review criteria upon which utilization review

decisions are based; and

(f) Additional standards, if any, for the consideration of special circumstances;

(2) The type and qualifications of the personnel either employed or under contract to

perform utilization review;

(3) Assurance that a toll -free line will be provided that covered persons, authorized

persons, and providers may use to contact the insurer or private review agent;

(4) The policies and procedures to ensure th at a representative of the insurer or private

review agent shall be reasonably accessible to covered persons, authorized persons,

and providers at least forty (40) hours per week during normal business hours;

(5) The policies and procedures to ensure that all applicable state and federal laws to

protect the confidentiality of individual medical records are followed;

(6) A copy of the materials designed to inform covered persons, authorized persons,

and providers of the toll -free number and the requirements of the utilization review

plan;

(7) A list of the entities for which the private review agent is performing utilization

review in this state; and

(8) Evidence of compliance or the ability to comply with the requirements and

procedures established regarding utilization review and the administrative

regulations promulgated thereunder.

(9) In lieu of disclosing information specified in subsection (1) of th is section, an

insurer or private review agent may submit to the department evidence of

accreditation or certification, if any, with a nationally recognized accreditation

organization that oversees the information described in subsections (1) to (8) of thi s

section, provided that the department may still require the information in subsection

(8) of this section or other information to demonstrate compliance with the

requirements of this section and KRS 304.17A -600, 304.17A -607, 304.17A -613,

304.17A-617, 304.17A-623, and 304.17A -625 not covered by the standards of the

nationally recognized accreditation organization, as well as basic information

necessary for the department to contact the insurer or private review agent. Nothing

in this subsection shall be construed to prohibit or in any way limit the department's

authority to require the submission of information specified in subsections (1) to (8)

of this section or any other information the department deems necessary for

purposes of investigating a complain t that the insurer or private review agent is not

in compliance with KRS 304.17A-600 to 304.17A-633.