KRS 304.32-147: Requirements for health service corporation that issues policy or

administers program providing for utilization review of benefits.

(1) Every nonprofit hospital, medical -surgical, dental, and health service corporation

proposing to issue or deliver in this state a health insurance policy or contract or

administer a health benefit program which provides for the coverage of hospital

benefits and the utilization review of those benefits by a private review agent shall:

(a) Be a registered private revie w agent in accordance with KRS 304.17A -607

and administrative 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, a nonprofit

hospital, medical-surgical, dental, and healt h service corporation 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 in form 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 appeal 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 appeal to the cabinet; and

(b) The nonprofit hospital, medical -surgical, dental, and health service

corporation is in compliance with subsection (1) of this section.