KRS 304.17B-011: Third-party administrator to administer Kentucky Access -- Selection

and duties -- Reimbursement for expenses.

(1) The Office of Health Data and Analytics shall select a third -party administrator,

through the state competitive bidding p rocess, to administer Kentucky Access. The

third-party administrator shall be an administrator licensed by the department. The

office shall consider criteria in selecting a third -party administrator that shall

include, but not be limited to, the following:

(a) A third-party administrator's proven ability to demonstrate performance of the

operations of an insurer to include the following: enrollee enrollment,

eligibility determination, provider enrollment and credentialing, utilization

management, quality im provement, drug utilization review, premium billing

and collection, claims payment, and data reporting;

(b) The total cost to administer Kentucky Access;

(c) A third -party administrator's proven ability to demonstrate that Kentucky

Access shall be administered in a cost-efficient manner;

(d) A third-party administrator's proven ability to demonstrate experience in two

(2) or more states administering a risk pool for a minimum of a three (3) year

period; and

(e) A third-party administrator's financial condition and stability.

(2) The office may contract with the third -party administrator for a period of four (4)

years with an option for a two (2) year extension as approved by the office on a

year-by-year contract basis. At least one (1) year prior to the expi ration of the third-

party administrator's contract, the office may solicit third -party administrators,

including the current third -party administrator, to submit bids to serve as the third -

party administrator for the succeeding four (4) year period.

(3) In addition to any duties and obligations set forth in the contract with the third-party

administrator, the third-party administrator shall:

(a) Develop and establish policies and procedures for enrollee enrollment,

eligibility determination, provider enroll ment and credentialing, utilization

management, case management, disease management, quality improvement,

drug utilization review, premium billing and collection, data reporting, and

other responsibilities determined by the office;

(b) Develop and establish policies and procedures for paying the agent referral fee

under KRS 304.17B-001 to 304.17B-031;

(c) Develop and establish policies and procedures to ensure timely and efficient

payment of claims to include, but not limited to, the following:

1. Develop a nd provide a claims billing manual to health care providers

enrolled in Kentucky Access that includes information relating to the

proper billing of a claim and the types of claim forms to use;

2. Payment of all claims in accordance with the provisions of this chapter,

KRS 304.12 -237, and the administrative regulations promulgated

thereunder; and

3. Notification to an enrollee through an explanation of benefits if a claim

is denied or if there is en rollee financial responsibility of a paid claim

for deductible or coinsurance amounts;

(d) Issue denial letters under KRS 304.17A-540 for denial of preauthorization and

precertification requests for medical necessity and medical appropriateness

determinations;

(e) Submit information to the office and the department under KRS 304.17A-330;

(f) Submit reports to the office regarding the operation and financial condition of

Kentucky Access. The frequency, content, and form of the reports shall be

determined by the office;

(g) Submit an annual report to the office three (3) months after the end of each

calendar year. The annual report shall include:

1. Earned premium;

2. Administrative expenses;

3. Incurred losses for the year;

4. Paid losses for the year;

5. Number of enrollees enrolled in Kentucky Access by category of

eligibility; and

6. Any other information requested by the office; and

(h) Be subject to examination by the office under Subtitles 2 and 3 of this chapter.

(4) The third-party administrator shall be paid for necessary and reasonable expenses,

as provided in the contract between the office and the third-party administrator.