KRS 304.17C-050: Standards for providers -- Mechanism for acting upon applications --

Policy governing removal of providers from network.

(1) Insurers shall establish relevant, objective standards for initial consideration of

providers and for providers to continu e as a participating provider in the plan.

Standards shall be reasonably related to services provided. Selection or participation

standards based on the economics or capacity of a provider's practice shall be

adjusted to account for case mix, severity of i llness, patient age, and other features

that may account for higher -than-expected or lower -than-expected costs. All data

profiling or other data analysis pertaining to participating providers shall be done in

a manner which is valid and reasonable. Plans shall not use criteria that would allow

an insurer to avoid high -risk populations by excluding providers because they are

located in geographic areas that contain populations or providers presenting a risk

of higher than average claims, losses, or health se rvices utilization, or that would

exclude providers because they treat or specialize in treating populations presenting

a risk of higher than average claims, losses, or health services utilization.

(2) Each insurer shall establish mechanisms for soliciting and acting upon applications

for provider participation in the plan in a fair and systematic manner. These

mechanisms shall, at a minimum, include:

(a) Allowing all providers who desire to apply for participation in the plan an

opportunity to apply at any time during the year, or, where an insurer does not

conduct open continuous provider enrollment, conducting a provider

enrollment period at least annually with the date publicized to providers

located in the geographic service area of the plan at least th irty (30) days in

advance of the enrollment period; and

(b) Making criteria for provider participation in the plan available to all

applicants.

(3) An insurer that offers a limited health service benefit plan shall establish a policy

governing the removal of and withdrawal by health care providers from the provider

network that includes the following:

(a) The insurer shall inform a participating health care provider of the insurer's

removal and withdrawal policy at the time the insurer contracts with the health

care provider to participate in the provider network, and when changed

thereafter;

(b) If a participating health care provider's participation will be terminated or

withdrawn prior to the date of the termination of the contract as a result of a

professional review action, the insurer and participating health care provider

shall comply with the standards in 42 U.S.C. sec. 11112; and

(c) If the insurer finds that a health care provider represents an imminent danger

to an individual patient or to the publ ic health, safety, or welfare, the medical

director shall promptly notify the appropriate professional state licensing

board.