KRS 304.17A-716: Prohibition against denial or reduction of payment for covered health

benefit -- Conditions.

(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 covered

under the covered person's health benefit plan if:

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

insurer or the insurer's designee or agent on the day the covered person is

expected to be discharged to re quest review of the covered person's continued

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

review decision within twenty -four (24) hours of the request and prior to the

time upon which any previous authorization will expire; or

(b) 1. 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 to request:

a. Review of a continued hospital stay;

b. Preauthorization of treatment for a covered person who is already

hospitalized; or

c. Retrospective review of an emergency hospital admission where

the covered person remains hospitalized at the time the review

requested is made; and

2. The insurer, designee, or private review agent fails to be accessible via a

toll-free telephone line for forty (40) hours per week during normal

business hours.

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

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

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

request for review of the matters addressed under 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 failure 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 concer ns 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 does not furnish the information requested by the insure r 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.