{"data":{"id":"us-ky/krs-205.8455","jurisdiction":"us-ky","citation":"KRS 205.8455","heading":"Recipient Utilization Review Committee -- Authority.","body":"(1) To implement provisions of this section, the commissioner of the Department for\nMedicaid Services shall create, no later than July 30, 1994, a Recipient Utilization\nReview Committee with the authority to:\n(a) Review individual recipient utilization or prog ram benefits, recipient medical\nrecords, and other additional information or data necessary to make a\ndecision;\n(b) Determine if a recipient has utilized the program or services in a fraudulent or\nabusive manner;\n(c) Refer cases of suspected recipient frau d to the Office of the Inspector General\nin the Cabinet for Health and Family Services;\n(d) Institute administrative actions to restrict or revoke the recipient's\nparticipation in the Medical Assistance Program; and\n(e) Initiate actions to recover the value of benefits received by the recipient which\nwere determined to be related to fraudulent or abusive activities.\n(2) The Recipient Utilization Review Committee shall be composed of five (5)\nmembers as follows: one (1) licensed physician, one (1) representa tive from the\nsame program benefit area that is the subject of the review, one (1) recipient or\nrepresentative of medical assistance benefits, one (1) representative of the\nSurveillance and Utilization Review Subsystems Unit, as required under Title XIX\nof the Social Security Act, and the commissioner of the Department for Public\nHealth, who shall serve by virtue of his or her office.\n(3) A medical assistance recipient whose eligibility has been revoked due to defrauding\nthe Medical Assistance Program shall  not be eligible for future medical assistance\nservices for a period of not more than one (1) year or until full restitution has been\nmade to the Department for Medicaid Services, whichever comes first.\n(4) When a medical assistance recipient whose eligibi lity has been revoked due to\ndefrauding of the Medical Assistance Program reapplies for coverage, during the\nperiod of revocation, due to pregnancy, a communicable disease, or other condition\nthat creates a risk to public health, or a condition which if no t treated could result in\nimmediate grave bodily harm, the recipient utilization review committee for the\nDepartment for Medicaid Services may change the revoked status of the previously\neligible recipient to restricted status if it has been determined tha t it would be in the\nbest interest of the previously eligible medical assistance recipient to receive\ncoverage for medical assistance services and the person is otherwise eligible. If this\nchange in status is granted, the case shall be reconsidered by the Recipient\nUtilization Review Committee within sixty (60) days after the restricted status takes\neffect.\n(5) Upon determination by the Recipient Utilization Review Committee of the\nDepartment for Medicaid Services that a medical assistance recipient has abused the\nbenefits of the Medical Assistance Program, the recipient shall immediately be\nassigned and restricted to a managed care primary physician designated by the\nDepartment for Medicaid Services. Except in the case of an emergency as defined\nby the recipient utilization review committee and set forth by the Cabinet for Health\nand Family Services in an administrative regulation promulgated pursuant to KRS\nChapter 13A, the restricted recipient shall be eligible to receive covered services\nonly upon present ing to a participating provider, prior to the receipt of services, a\ndated written referral by the assigned managed care primary physician. Any\nparticipating provider who provides services to a medical assistance recipient in\nviolation of the provisions of this subsection shall not be eligible for reimbursement\nfor any services rendered.\n(6) The Cabinet for Health and Family Services shall request any waivers of federal law\nthat are necessary to implement the provisions of this section.\n(7) The provisions o f paragraphs (d) and (e) of subsection (1) of this section and of\nsubsections (3), (4), and (5) of this section shall have no force or effect until and\nunless the requested waivers are granted.\n(8) Nothing in this section shall authorize the Cabinet for He alth and Family Services\nto waive the recipient's or provider's rights to prior notice and hearing as guaranteed\nby federal law.\n(9) All complaints received by the Department for Medicaid Services, the Office of the\nInspector General, the Office of the Att orney General, or by personnel of the\nCabinet for Health and Family Services concerning possible fraud or abuse by a\nmedical assistance recipient shall be forwarded immediately to the Recipient\nUtilization Review Committee for its consideration. Any cases of possible recipient\nfraud or abuse uncovered by personnel of the Cabinet for Health and Family\nServices or by providers shall also be referred immediately to the Recipient\nUtilization Review Committee for its review. Records shall be kept of all cases,\nincluding records of disposition, considered by the Recipient Utilization Review\nCommittee.","path":["KRS Chapter 205"],"source_url":"https://apps.legislature.ky.gov/law/statutes/statute.aspx?id=7853","current_through":"Includes enactments through the 2026 Regular Session","vintage":"09/05/2026","retrieved_at":"2026-09-05T20:52:05Z","sha256":"881bbd19108a4e5656a8b4e78313e21bbd4af604b0e4103cc0626c50986021ae","source_id":"us-ky","stale":false,"prev":"us-ky/krs-205.8453","next":"us-ky/krs-205.8457"},"notice":"GroundRules: Original legal text. Not legal advice."}