KRS 304.17A-617: Internal appeals process -- Procedures -- Review of coverage denials.

(1) (a) Every insurer shall have an internal appeal process for adverse benefit

determinations that is:

1. Utilized by the insurer or its designee, consistent w ith this section and

KRS 304.17A-619; and

2. Disclosed to covered persons in accordance with KRS 304.17A -

505(1)(g).

(b) An insurer shall disclose the availability of the internal appeal process to the

covered person in the insured's timely notice of an adv erse benefit

determination which meets the requirements in KRS 304.17A-607(2)(j).

(c) Where a coverage denial is involved, in addition to stating the reason for the

coverage denial, the required notice shall contain instructions for filing a

request for internal appeal.

(2) The internal appeals process may be initiated by the covered person, an authorized

person, or a provider acting on behalf of the covered person.

(3) The internal appeals process shall include adequate and reasonable procedures for

review and resolution of appeals concerning adverse benefit determinations,

including procedures for reviewing appeals from covered persons whose medical

conditions require expedited review.

(4) At a minimum, the p rocedures required under subsection (3) of this section shall

include the following:

(a) Except as provided in KRS 304.17A -163, insurers or their designees shall

provide decisions to covered persons, authorized persons, and providers on

internal appeals:

1. Within thirty (30) days of receipt of the request for internal appeal,

except as provided in subparagraph 2. of this paragraph; or

2. Not later than three (3) business days after receipt of a request for an

expedited appeal of an adverse benefit determin ation. An expedited

appeal is deemed necessary when a covered person is hospitalized or, in

the opinion of the treating provider, review under a standard time frame

could, in the absence of immediate medical attention, result in any of the

following:

a. Placing the health of the covered person or, with respect to a

pregnant woman, the health of the covered person or the unborn

child in serious jeopardy;

b. Serious impairment to bodily functions; or

c. Serious dysfunction of a bodily organ or part;

(b) Internal appeal of an adverse benefit determination, other than a coverage

denial, shall only be conducted by a licensed physician who did not

participate in the initial review and denial, except in the case of a review

involving a medical or surgical specialty or subspecialty, the insurer or agent

shall, upon request by a covered person, authorized person, or provider, utilize

a board -eligible or certified physician in the appropriate specialty or

subspecialty area to conduct the internal appeal;

(c) Those portions of the medical record that are relevant to the internal appeal, if

authorized by the covered person and in accordance with state or federal law,

shall be considered and providers given the opportunity to present additional

information; and

(d) In addition to any previous notice required under KRS 304.17A-607(2)(j), and

to facilitate expeditious handling of a request for external review or review of

a coverage denial under subsection (5) of this section, an insurer or agent that

denies, limits, reduces, or terminates coverage for a service, treatment,

procedure, drug, supply, or device for a covered person shall provide the

covered person, authorized person, or provider acting on behalf of the covered

person with an internal appeal determination letter that includes:

1. A statement of the specific medical and scientific reasons for denying

coverage or identifying that provision of the schedule of benefits or

exclusions that demonstrates that coverage is not available;

2. As applicable, the state of licens ure and the title of the person making

the decision, except that an internal appeal determination letter provided

to a provider acting on behalf of the covered person shall also include

the medical license number of the person making the decision;

3. Except for retrospective review, a description of alternative benefits,

services, or supplies covered by the health benefit plan, if any; and

4. Instructions for:

a. Initiating an external review; or

b. For coverage denials, filing a request for review with th e

department under subsection (5) of this section.

(5) (a) The department shall establish and maintain a system for receiving and

reviewing requests for review of coverage denials from covered persons,

authorized persons, and providers.

(b) For purposes of this subsection, "coverage denials" shall not include

subsequent denials arising from an adverse benefit determination that is not a

coverage denial.

(c) On receipt of a written request for review of a coverage denial from a covered

person, authorized person, or provider, the department shall:

1. Notify the insurer that issued the denial of the request for review; and

2. Call for the insurer to respond to the department regarding the request

for review within ten (10) business days of receipt of notice to the

insurer.

(d) Within ten (10) business days of receiving the notice of the request for review

from the department, the insurer shall provide to the department the following

information:

1. Confirmation as to whether the person who received or sought the

service, procedure, treatment, drug, supply, or device for which

coverage was denied was a covered person under a health benefit plan

issued by the insurer on the date the service, procedure, treatment, drug,

supply, or device was sought or denied;

2. Confirmation as to whether the covered person, authorized person, or

provider has exhausted his or her rights under the insurer's internal

appeal process under this section; and

3. The reason for the coverage denial, including the specific limitation or

exclusion of the health benefit plan demonstrating that coverage is not

available.

(e) In addition to the information described in paragraph (d) of this subsection,

the insurer and the covered person, authorized person, or provider shall

provide to the department any information requested by the department that is

germane to its review.

(f) 1. On the receipt of the information des cribed in paragraphs (d) and (e) of

this subsection, unless the department is not able to do so because

making a determination requires resolution of a medical issue, it shall

determine whether the service, procedure, treatment, drug, supply, or

device is specifically limited or excluded under the terms of the covered

person's health benefit plan.

2. If the department determines that the service, procedure, treatment,

drug, supply, or device is not specifically limited or excluded, it shall so

notify the in surer, and the insurer shall either cover the service,

procedure, treatment, drug, supply, or device or afford the covered

person an opportunity for external review, where the conditions

precedent to the review are present.

3. If the department notifies th e insurer that the service, procedure,

treatment, drug, supply, or device is specifically limited or excluded in

the health benefit plan, the insurer is not required to cover the service,

procedure, treatment, drug, supply, or device or afford the covered

person an external review.

(g) An insurer shall be required to cover the service, procedure, treatment, drug,

supply, or device that was denied or provide notification of the right to

external review in accordance with paragraph (f) of this subsection whet her

the covered person has disenrolled or remains enrolled with the insurer.

(h) If the covered person has disenrolled with the insurer, the insurer shall only be

required to provide the service, procedure, treatment, drug, supply, or device

that was denie d for a period not to exceed thirty (30) days or provide the

covered person the opportunity for external review.