{"data":{"id":"us-ky/krs-304.17a-545","jurisdiction":"us-ky","citation":"KRS 304.17A-545","heading":"Medical director for managed care plan -- Duties -- Quality assurance","body":"or improvement standards -- Process to select health care providers -- Uniform\napplication form and guidelines for health care provider evaluations.\n(1) A managed care plan shall appoint a medical director who:\n(a) Is a physician licensed to practice in this state;\n(b) Is in good standing with the State Board of Medical Licensure;\n(c) Has not had his or her license revoked or suspended under KRS 311.530 to\n311.620; and\n(d) Shall be responsible for the treatment policies, protocols, quality assurance\nactivities, and utilization management decisions of the plan.\n(2) The medical director shall ensure that:\n(a) Any utilization management decision to deny, reduce, or terminate  a health\ncare benefit or to deny payment for a health care service because that service\nis not medically necessary shall be made by a physician, except in the case of\na health care service rendered by a chiropractor or optometrist, that decision\nshall be made respectively by a chiropractor or optometrist duly licensed in\nKentucky;\n(b) A utilization management decision shall not retrospectively deny coverage for\nhealth care services provided to a covered person when prior approval has\nbeen obtained from the  insurer for those services, unless the approval was\nbased upon fraudulent, materially inaccurate, or misrepresented information\nsubmitted by the covered person or the participating provider;\n(c) In the case of a managed care plan, a procedure is implemented whereby:\n1. Participating physicians have an opportunity to review and comment on\nall medical and surgical and emergency room protocols, respectively, of\nthe insurer; and\n2. Other participating providers have an opportunity to review and\ncomment on all of the insurer's protocols that are within the provider's\nlegally authorized scope of practice;\n(d) The utilization management program is available to respond to authorization\nrequests for urgent services and is available, at a minimum, during normal\nworking hours for inquiries and authorization requests for nonurgent health\ncare services; and\n(e) In the case of a managed care plan, a covered person is permitted to choose or\nchange a primary care provider from among participating providers in the\nprovider network and, when appropriate, choose a specialist from among\nparticipating network providers following an authorized referral, if required\nby the insurer, and subject to the abi lity of the specialist to accept new\npatients.\n(3) A managed care plan shall develop comprehensive quality assurance or\nimprovement standards adequate to identify, evaluate, and remedy problems\nrelating to access, continuity, and quality of health care ser vices. These standards\nshall be made available to the public during regular business hours and include:\n(a) An ongoing written, internal quality assurance or improvement program;\n(b) Specific written guidelines for quality of care studies and monitoring,\nincluding attention to vulnerable populations;\n(c) Performance and clinical outcomes-based criteria;\n(d) A procedure for remedial action to correct quality problems, including written\nprocedures for taking appropriate corrective action;\n(e) A plan for data gathering and assessment; and\n(f) A peer review process.\n(4) Each managed care plan shall have a process for the selection of health care\nproviders who will be on the plan's list of participating providers, with written\npolicies and procedures for review and approval used by the plan.\n(a) The plan shall establish minimum professional requirements for participating\nhealth care providers. An insurer may not discriminate against a provider\nsolely on the basis of the provider's license by the state;\n(b) The plan shall demonstrate that it has consulted with appropriately qualified\nhealth care providers to establish the minimum professional requirements;\n(c) The plan's selection process shall include verification of each health care\nprovider's license, history of license suspension or revocation, and liability\nclaims history;\n(d) A managed care plan shall establish a formal written, ongoing process for the\nreevaluation of each participating health care provider within a specified\nnumber of years after the provider' s initial acceptance into the plan. The\nreevaluation shall include an update of the previous review criteria and an\nassessment of the provider's performance pattern based on criteria such as\nenrollee clinical outcomes, number of complaints, and malpractice actions.\n(5) The commissioner shall promulgate administrative regulations to establish a\nuniform application form and guidelines for the evaluation and reevaluation of\nhealth care providers, including psychologists, who will be on the plan's list of\nparticipating providers in accordance with subsection (4) of this section. In\ndeveloping a uniform application and guidelines, the department shall consider\nindustry standards and guidelines adopted by the Council for Affordable Quality\nHealthcare. The uniform application form and guidelines shall be used by all\ninsurers.\n(6) A managed care plan shall not use a health care provider beyond, or outside of, the\nprovider's legally authorized scope of practice.","path":[],"source_url":"https://apps.legislature.ky.gov/law/statutes/statute.aspx?id=56517","current_through":"Includes enactments through the 2026 Regular Session","vintage":"09/05/2026","retrieved_at":"2026-09-05T20:57:47Z","sha256":"7d7b7906ac790d89208bc2db838de166f0e0db1d6f493522548bbf97da7692e7","source_id":"us-ky","stale":false,"prev":"us-ky/krs-304.17a-540","next":"us-ky/krs-304.17a-550"},"notice":"GroundRules: Original legal text. Not legal advice."}