KRS 304.17A-700: Definitions for KRS 304.17A -700 to 304.17A -730 and KRS 205.593,

304.14-135, and 304.99-123.

As used in KRS 304.17A -700 to 304.17A -730 and KRS 205.593, 304.14 -135, and

304.99-123:

(1) "Adjudicate" means an insurer pays, contests, or denies a clean claim;

(2) "Claims payment time frame" means the time period prescribed under KRS

304.17A-702 following receipt of a clean claim from a provider at the address

published by the insurer, whether it is the address of the insurer or a delegated

claims processor, within which an insurer is required to pay, contest, or deny a

health care claim;

(3) "Clean claim" means a properly completed billing instrument, paper or electronic,

including the required health claim attachments, submitted in the following

applicable form:

(a) A clean claim from an institutional provider shall consist of:

1. The UB-92 data set or its successor submitted on the designated paper or

electronic format as adopted by the NUBC;

2. Entries stated as mandatory by the NUBC; and

3. Any state-designated data requirements determined and approved by the

Kentucky State Uniform Billing Committee and included in the UB -92

billing manual effective at the time of service.

(b) A clean claim for dentists shall consist of the form and data set appr oved by

the American Dental Association.

(c) A clean claim for all other providers shall consist of the HCFA 1500 data set

or its successor submitted on the designated paper or electronic format as

adopted by the National Uniform Claims Committee.

(d) A clean claim for pharmacists shall consist of a universal claim form and data

set approved by the National Council on Prescription Drug Programs;

(4) "Commissioner" means the commissioner of the Department of Insurance;

(5) "Covered person" means a person on whose behalf an insurer offering a health

benefit plan is obligated to pay benefits or provide services;

(6) "Department" means the Department of Insurance;

(7) "Electronic" or "electronically" means electronic mail, comp uterized files,

communications, or transmittals by way of technology having electrical, digital,

magnetic, wireless, optical, electromagnetic, or similar capabilities;

(8) "Health benefit plan" has the same meaning as provided in KRS 304.17A-005;

(9) "Health care provider" or "provider" means a provider licensed in Kentucky as

defined in KRS 304.17A -005 and, for the purposes of KRS 304.17A -700 to

304.17A-730 and KRS 205.532, 205.593, 304.14 -135, and 304.99 -123 only, shall

include physical therapists licensed under KRS Chapter 327, psychologists licensed

under KRS Chapter 319, and social workers licensed under KRS Chapter 335.

Nothing contained in KRS 304.17A -700 to 304.17A -730 and KRS 205.593,

304.14-135, and 304.99 -123 shall be construed to include physical therapists,

psychologists, and social workers as a health care provider or provider under KRS

304.17A-005;

(10) "Health claim attachments" means medical information from a covered person's

medical record required by the insurer containing medical informat ion relating to

the diagnosis, the treatment, or services rendered to the covered person and as may

be required pursuant to KRS 304.17A-720;

(11) "Institutional provider" means a health care facility licensed under KRS Chapter

216B;

(12) "Insurer" has the same meaning provided in KRS 304.17A-005;

(13) "Kentucky Uniform Billing Committee (KUBC)" means the committee of health

care providers, governmental payors, and commercial insurers established as a local

arm of NUBC to implement the bill requirements of the NUBC and to prescribe any

additional billing requirements unique to Kentucky insurers;

(14) "National Uniform Billing Committee (NUBC)" means the national committee of

health care providers, governmental payors, and commercial insurers that develops

the national uniform billing requirements for institutional providers as referenced in

accordance with the Federal Health Insurance Portability and Accountability Act of

1996, 42 U.S.C. Chapter 6A, Subchapter XXV, secs. 300gg et seq.;

(15) "Retrospective review" means utilization review that is conducted after health care

services have been provided to a covered person; and

(16) "Utilization review" has the same meaning as provided in KRS 304.17A-600.