{"data":{"id":"us-ky/krs-205.6315","jurisdiction":"us-ky","citation":"KRS 205.6315","heading":"Requirements when private peer review organization is contracted with","body":"to conduct reviews of levels of care.\nWhen the cabinet contracts with any private peer review organization to conduct\nutilization reviews of the levels of care of the state's Medic aid program recipients, the\nfollowing shall apply:\n(1) In determining the appropriate level of care of a Medicaid beneficiary who is a\npatient in a nursing facility setting, and prior to any change that reduces a Medicaid\nbeneficiary's eligibility for covered services, the contracted peer review organization\nshall assure that:\n(a) An in-person assessment of the Medicaid beneficiary is made; and\n(b) A licensed physician has reviewed the written documentation of the peer\nreview organization's evaluation and p rovided a written review of the\nevaluation to be a part of the patient's record.\n(2) If the level of care is changed for a Medicaid beneficiary who is a resident or patient\nin a nursing facility setting or a Medicaid beneficiary who receives community -\nbased waiver services, and the change makes that beneficiary ineligible for the\nMedicaid covered service, the peer review organization shall notify the\ncommissioner of Medicaid in the cabinet, and shall provide a written notification\nsent by registered return receipt mail to the affected Medicaid beneficiary, nursing\nfacility, affected Medicaid beneficiary's attending physician, and the affected\nbeneficiary's responsible party.\n(3) If the level of care for a Medicaid beneficiary results in an adverse determinat ion,\nthe affected Medicaid beneficiary, or the responsible person or party, may appeal\nthrough an application for reconsideration to be filed with the cabinet within ten\n(10) days from the date of receipt of the registered return receipt written\nnotification. If the responsible party's registered return receipt mail is undeliverable,\nthe attending physician may initiate the appeal on behalf of the affected Medicaid\nbeneficiary.\n(a) All benefits which the affected Medicaid recipient, and the nursing facility are\neligible for shall be continued during that ten (10) day time frame; and\n(b) As long as the affected Medicaid recipient is engaged in an appeal of an\nadverse determination from a peer review organization, all benefits for which\nthe affected Medicaid r ecipient and nursing facility are eligible shall be\ncontinued until an appropriate residential setting is secured, in any event, not\nto exceed ninety (90) days from the date of the request for a hearing, or until a\nfinal determination is made by a hearing officer.\n(4) (a) If the level of care is lowered for a Medicaid beneficiary who is a resident or\npatient in a nursing facility setting, an independent examination may be\nconducted by the resident's attending physician.\n(b) If the resident's attending physician conducts an independent examination, the\nattending physician shall make a recommendation concerning the appropriate\nlevel of care and forward, in writing, the results of the examination and the\nrecommendation to the peer review organization, the affec ted recipient, the\nnursing facility, and the responsible party.\n(5) For the purposes of this section, \"responsible person or party\" shall mean an\nindividual authorized by the resident of the facility to act for the resident as an\nofficial delegate or agent. The responsible person may be a guardian, payee, family\nmember, or any other individual who has arranged for the care of the resident and\nassumed this responsibility. The responsible party may or may not be related to the\nresident. A responsible person o r party is not a guardian unless so appointed by the\ncourt.\n(6) The peer review organization shall:\n(a) Inform the patient and guardian, responsible party, or family member, upon\ninitial qualification for Medicaid covered services, and with the written\nnotification of an adverse determination from a peer review organization:\n1. Of the manner in which notific ation of any adverse decision will be\nmade;\n2. Of the process for securing a timely review of any adverse decision;\n3. That a request for reconsideration must be postmarked no later than ten\n(10) days after receipt of the initial written notification of an y adverse\ndecision;\n4. Of the toll -free line that will be provided for questions regarding\nreviews; and\n5. Of the process for appealing an adverse reconsideration to the cabinet;\n(b) Provide a written peer review organization physician review of all advers e\ndeterminations;\n(c) Provide for an attending physician review of all adverse determinations as\noutlined in subsection (4) of this section;\n(d) Inform the commissioner of all information related to an appeal of an adverse\naction; and\n(e) Provide the infor mation identified in paragraph (a) of this subsection, at the\ntime of an adverse determination notification, to any affected nursing facility\nin which a Medicaid beneficiary resides.","path":["KRS Chapter 205"],"source_url":"https://apps.legislature.ky.gov/law/statutes/statute.aspx?id=7760","current_through":"Includes enactments through the 2026 Regular Session","vintage":"09/05/2026","retrieved_at":"2026-09-05T20:52:04Z","sha256":"d54275d68abd1c284075d1425a1f3babcc9b0d56528c8f419bf6c638ef4b3345","source_id":"us-ky","stale":false,"prev":"us-ky/krs-205.6314","next":"us-ky/krs-205.6316"},"notice":"GroundRules: Original legal text. Not legal advice."}