KRS 304.17A-627: Certification as independent review entity -- Requirements and

restrictions.

(1) To be certified as an independent review entity under this chapter, an organization

shall submit to the department an application on a form required by the department .

The application shall include the following:

(a) The name of each stockholder or owner of more than five percent (5%) of any

stock or options for an applicant;

(b) The name of any holder of bonds or notes of the applicant that exceeds one

hundred thousand dollars ($100,000);

(c) The name and type of business of each corporation or other organization that

the applicant controls or with which it is affiliated and the nature and extent of

the affiliation or control;

(d) The name and a biographical sketch of each director, officer, and executive of

the applicant and any entity listed under paragraph (c) of this subsection and a

description of any relationship the named individual has with an insurer as

defined in KRS 304.17A-600 or a provider of health care services;

(e) The percentage of the applicant's revenues that are anticipated to be derived

from independent reviews;

(f) A description of the minimum qualifications employed by the independent

review entity to select health care professionals to perform ext ernal review,

their areas of expertise, and the medical credentials of the health care

professionals currently available to perform external reviews; and

(g) The procedures to be used by the independent review entity in making review

determinations.

(2) If at any time there is a material change in the information included in the

application, provided for in subsection (1) of this section, the independent review

entity shall submit updated information to the department.

(3) An independent review entity shall not be a subsidiary of, or in any way affiliated

with, or owned, or controlled by an insurer or a trade or professional association of

payors.

(4) An independent review entity shall not be a subsidiary of, or in any way affiliated

with, or owned, or controlled by a trade or professional association of providers.

(5) Health care professionals who are acting as reviewers for the independent review

entity shall hold in good standing a nonrestricted license in a state of the United

States.

(6) Health care prof essionals who are acting as reviewers for the independent review

entity shall hold a current certification by a recognized American medical specialty

board or other recognized health care professional boards in the area appropriate to

the subject of the re view, be a specialist in the treatment of the covered person's

medical condition under review, and have actual clinical experience in that medical

condition.

(7) The independent review entity shall have a quality assurance mechanism to ensure

the timeliness and quality of the review, the qualifications and independence of the

physician reviewer, and the confidentiality of medical records and review material.

(8) Neither the independent review entity nor any reviewers of the entity, shall have any

material, professional, familial, or financial conflict of interest with any of the

following:

(a) The insurer involved in the review;

(b) Any officer, director, or management employee of the insurer;

(c) The provider proposing the service or treatment or any associated independent

practice association;

(d) The institution at which the service or treatment would be provided;

(e) The development or manufacture of the principal drug, device, procedure, or

other therapy proposed for the covered person whos e treatment is under

review; or

(f) The covered person.

(9) As used in this section, "conflict of interest" shall not be interpreted to include:

(a) A contract under which an academic medical center or other similar medical

center provides health care serv ices to covered persons, except for academic

medical centers that may provide the service under review;

(b) Provider affiliations which are limited to staff privileges; or

(c) A specialist reviewer's relationship with an insurer as a contracting health care

provider, except for a specialist reviewer proposing to provide the service

under review.

(10) On an annual basis, the independent review entity shall report to the department the

following information:

(a) The number of independent review decisions in favor of covered persons;

(b) The number of independent review decisions in favor of insurers;

(c) The average turnaround time for an independent review decision;

(d) The number of cases in which the independent review entity did not reach a

decision in the time specified in statute or administrative regulation; and

(e) The reasons for any delay.