KRS 304.17A-615: Prohibition against denying or reducing payments under certain

circumstances.

(1) No insurer or any other person providing or administering a health benefit plan shall

deny or reduce payment for a service, procedure, treatment, drug or device cove red

under the covered person's health benefit plan if:

(a) The covered person's provider, during normal business hours, contacts the

insurer, the designee, or agent on the day the covered person is expected to be

discharged, in order to request review of t he covered person's continued

hospitalization, and the insurer, designee, or agent fails to provide a timely

utilization review decision as required by KRS 304.17A-607; or

(b) The covered person's provider makes at least three (3) documented attempts

during a four (4) consecutive hour period to contact the insurer, designee, or

agent, during normal business hours in order to request review of a continued

hospital stay, preauthorization of treatment for a covered person who is

already hospitalized, or retros pective review of an emergency hospital

admission where the covered person remains hospitalized at the time the

review requested is made, and the insurer, designee, or private review agent

fails to be accessible as required by KRS 304.17A-607.

(2) The insu rer's liability to pay for the covered person's hospitalization under the

circumstances set forth in subsection (1) of this section shall extend until the

insurer, designee, or private review agent issues a utilization review decision

applicable to requests for review relating to matters as set forth in subsection 1(b) of

this section.

(3) The insurer's liability to pay under this section shall be conditioned on:

(a) The provider establishing verifiable documentation of the contact with, and

subsequent fail ure of the insurer, designee, or agent to make the utilization

review decision as set forth in subsection (1)(a) of this section; or

(b) The provider establishing verifiable documentation of the attempt to make

contact with the insurer, designee, or agent as addressed in subsection (1)(b)

of this section.

(4) In either instance, the contact, or attempts to contact, as set forth in this section,

shall be made by the means required by the insurer, designee, or agent for

requesting utilization review.

(5) This section applies only when the request for review concerns covered health

benefits and it shall not supersede any limitations or exclusions in the covered

person's health benefit plan. This section shall not apply if, in requesting a review,

the provider d oes not furnish the information requested by the insurer or agent to

make a utilization review decision, or if actions by the provider impede an insurer's

or private review agent's ability to issue a utilization review decision.