KRS 304.17A-623: External review of adverse benefit determination -- Who may request

-- Criteria for review -- Fee -- Conditions under which covered person not

entitled to review -- Resolution of disputes -- Confidentiality -- Expedited

external review.

(1) (a) Every insurer shall have an external review process to be utilized by the

insurer or its designee, consistent with this section and which shall be

disclosed to covered persons in accordance with KRS 304.17A-505(1)(g).

(b) An insurer, its designee, or agent shall disclose the availability of the external

review process to the covered person in the insured's timely notice of an

adverse benefit determination, other than a coverage denial, as set forth in

KRS 304.17A -607(2)(j) and in the denial lette r required in KRS 304.17A -

617(1) and (4)(d).

(2) A covered person, an authorized person, or a provider acting on behalf of and with

the consent of the covered person, may request an external review of an adverse

benefit determination, other than a coverage denial, rendered by an insurer, its

designee, or agent.

(3) Except as provided in KRS 304.17A -163, the insurer shall provide an external

review if the following criteria are met:

(a) The insurer, its designee, or agent has rendered an adverse benefit

determination, other than a coverage denial;

(b) The covered person has completed the insurer's internal appeal process or the

insurer has failed to make a timely determination or notification as set forth in

KRS 304.17A -619(2). The insurer and the covered per son may, however,

jointly agree to waive the internal appeal requirement;

(c) The covered person was enrolled in the health benefit plan on the date of

service or, if a prospective denial, the covered person was enrolled and

eligible to receive covered ben efits under the health benefit plan on the date

the proposed health care service was requested; and

(d) The entire course of treatment or service will cost the covered person at least

one hundred dollars ($100) if the covered person had no insurance.

(4) (a) The covered person, an authorized person, or a provider with consent of the

covered person shall submit a request for external review to the insurer within

sixty (60) days, except as set forth in KRS 304.17A -619(1), of receiving

notice that an adverse benefit determination, other than a coverage denial, has

been timely rendered under the insurer's internal appeal process.

(b) As part of the request, the covered person shall provide to the insurer or its

designee written consent authorizing the indep endent review entity to obtain

all necessary medical records from both the insurer and any provider utilized

for review purposes regarding the determination.

(5) (a) The covered person shall be assessed a one (1) time filing fee of twenty -five

dollars ($25) that:

1. Shall be paid to the independent review entity; and

2. May be waived if the independent review entity determines that the fee

creates a financial hardship on the covered person.

(b) The fee shall be refunded if the independent review entity finds in favor of the

covered person.

(6) A covered person shall not be afforded an external review if:

(a) The subject of the covered person's external review request has previously

gone through the external review process and the independent review entity

found in favor of the insurer; and

(b) No relevant new clinical information has been submitted to the insurer since

the independent review entity found in favor of the insurer.

(7) (a) The department shall establish a system for each insurer to be assigned a n

independent review entity for external reviews.

(b) The system established by the department shall:

1. Be prospective; and

2. Require insurers to utilize independent review entities on a rotating basis

so that an insurer does not have the same independen t review entity for

two (2) consecutive external reviews.

(c) The department shall contract with no less than two (2) independent review

entities.

(8) (a) If a dispute arises between an insurer and a covered person regarding the

covered person's right to a n external review, the covered person may file a

complaint with the department.

(b) Within five (5) days of receipt of the complaint, the department:

1. Shall render a decision; and

2. May direct the insurer to submit the dispute to an independent review

entity for an external review if it finds all of the requirements of

subsection (3) of this section have been met.

(c) The complaint process established in this section shall:

1. Be separate and distinct from, and in no way limit, other grievance or

complaint processes available to consumers under other provisions of

the Kentucky Revised Statutes or duly promulgated administrative

regulations; and

2. Not limit, alter, or supplant the mechanisms for appealing coverage

denials established in KRS 304.17A-617.

(9) The external review process shall be confidential and shall not be subject to KRS

61.805 to 61.850 and KRS 61.870 to 61.884.

(10) External reviews shall be conducted in an expedited manner by the independent

review entity if:

(a) The covered person is hospitalized; or

(b) In the opinion of the treating provider, review under the standard time frame

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

following:

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

woman, the health of the covered person or her unborn child in serious

jeopardy;

2. Serious impairment to bodily functions; or

3. Serious dysfunction of a bodily organ or part.

(11) Requests for expedited external review shall be forwarded by the insurer to the

independent review entity within twenty-four (24) hours of receipt by the insurer.

(12) (a) For expedited external review, a determination shall be made by the

independent review entity within twenty -four (24) hours from the receipt of

all information required from the insurer.

(b) An extension of up to twenty -four (24) hours may be allowed if the covered

person and the insurer or its designee agree.

(c) The insurer or its designe e shall provide notice to the independent review

entity and to the covered person, by same -day communication, that the

external review request has been assigned to an independent review entity for

expedited review.

(13) (a) External reviews which are not e xpedited shall be conducted by the

independent review entity and a determination made within twenty -one (21)

calendar days from the receipt of all information required from the insurer.

(b) An extension of up to fourteen (14) calendar days may be allowed i f the

covered person and the insurer are in agreement.