KRS 304.18-045: Requirements for insurer that issues policy or administers program

providing for utilization review of benefits.

(1) Every health insurer proposing to issue or deliver in this state a group or blanket

health insurance policy or contract or administ er a health benefit program which

provides for the coverage of hospital benefits and the utilization review of those

benefits by an insurer, its designee, or a private review agent shall:

(a) Be registered in accordance with KRS 304.17A -607 and administrat ive

regulations promulgated under the authority of KRS 304.17A-613; or

(b) Contract with a private review agent that has been registered in accordance

with KRS 304.17A-607 and administrative regulations promulgated under the

authority of KRS 304.17A-613.

(2) Notwithstanding any other provision of KRS 304.17A-603, 304.17A-605, 304.17A-

607, 304.17A-609, 304.17A-611, 304.17A-613, and 304.17A -615, an insurer or its

designee shall not deny or reduce payment of health benefits to any person, licensed

practitioner, or health facility for covered services which have been rendered to an

insured unless:

(a) Notice of denial has been issued. The notice shall inform patients, authorized

persons, and health -care providers of their right to appeal adverse

determinations of a utilization review by the insurer, its designee, or private

review agent to the insurer for the internal review process established by the

insurer in accordance with KRS 304.17A -617 and 304.17A -619. The notice

shall also include instructions on filing an internal appeal; and

(b) The insurer is in compliance with subsection (1) of this section.