KRS 304.17A-613: Emergency administrative regulations governing registration of

insurers and private review agents seeking to conduct utilization reviews --

Procedure for handling complaints.

(1) The department shall, through the promulgation of emergency administ rative

regulations, develop a process:

(a) For the review of applications for registration of insurers or private review

agents seeking to conduct utilization reviews;

(b) For the review of applications for insurers or private review agents seeking

registration renewal to continue as a utilization review entity;

(c) Ensuring that no registration shall be approved unless the commissioner has

documentation or findings that all applicants seeking registration or renewal to

conduct utilization review are in com pliance with the requirements and

procedures established regarding utilization review, and as to renewals, have

complied with KRS 304.17A -600 to 304.17A -633 and administrative

regulations promulgated to enforce and to administer KRS 304.17A -600 to

304.17A-633; and

(d) Establishing fees for applications and renewals in an amount sufficient to pay

the administrative costs of the program and any other costs associated with

carrying out the provisions of 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.

(2) The registration issued in accordance with this section expires on the second

anniversary of the effective date unless it is renewed.

(3) The registration issued under this section is not transferable.

(4) The commissioner may revoke or suspend the utilization review registration of any

insurer or private review agent who does not comply with the requirements and

procedures established regarding utilization review or any administrative

regulations promulgated thereunder.

(5) The department shall establish reporting requirements to:

(a) Evaluate the effectiveness of insurers and private review agents; and

(b) Determine if the utilization review plans are in compliance with the

requirements and procedu res established regarding utilization review and

applicable administrative regulations.

(6) Upon request of any provider, authorized person, or covered person whose care is

subject to review, the department shall provide copies of policies or procedures of

any insurer or private review agent that has been issued a registration by the

department to conduct review in this state.

(7) Notwithstanding any provision to the contrary, an insurer or private review agent

registered and in good standing under the prov isions of KRS 211.461 to 211.466,

prior to July 14, 2000, shall be deemed in compliance with requirements and

procedures established in KRS 304.17A -600 to 304.17A -633 regarding utilization

review and registered accordingly.

(8) Upon receipt of written comp laints from covered persons, authorized persons, or

providers stating that an insurer or a private review agent has failed to perform a

review in accordance with the utilization review plan or the requirements and

procedures established regarding utilizati on review, or administrative regulations

promulgated thereunder, the commissioner shall:

(a) Send a copy of the complaint to the insurer or the private review agent within

ten (10) days of receipt of the complaint, and require that any written reply be

sent to the commissioner within ten (10) days; and

(b) Review the complaint and any written repl y received from the insurer or

private review agent within the time frames set forth in paragraph (a) of this

subsection and make a recommendation to the insurer or private review agent

and the covered person, authorized person, or provider.

(9) The commis sioner shall consider complaints before issuing or renewing any

registration or renewal of a registration to an insurer or a private review agent.

(10) Notwithstanding any provision in this section to the contrary, the department shall

accept accreditation or certification by a nationally recognized accreditation

organization as sufficient documentation or finding for purposes of subsections (1)

and (5) of this section that the insurer or private review agent meets the application

requirements for registrat ion or renewal. Insurers or private review agents

accredited or certified by a nationally recognized accreditation organization shall be

deemed compliant with the utilization review and internal appeals requirements of

this section and KRS 304.17A -600, 304 .17A-607, 304.17A -609, 304.17A -617,

304.17A-623, and 304.17A -625 and administrative regulations to the extent the

standards of such nationally recognized accreditation organization sufficiently meet

these requirements. The department shall have a simplifie d process in

administrative regulations for insurers and private review agents to register using

accreditation or certification and shall limit any additional documentation only for

demonstrating compliance with requirements in this section and KRS 304.17A -600,

304.17A-607, 304.17A-609, 304.17A-617, 304.17A-623, and 304.17A-625 not met

by the standards of a nationally recognized accreditation organization.