{"data":{"id":"us-ky/krs-304.17a-600","jurisdiction":"us-ky","citation":"KRS 304.17A-600","heading":"Definitions for KRS 304.17A-600 to 304.17A-633.","body":"As used in KRS 304.17A-600 to 304.17A-633:\n(1) \"Adverse benefit determination\":\n(a) Has the same meaning as in 29 C.F.R. sec. 2560.503-1, as amended; and\n(b) Includes:\n1. A determina tion by an insurer or its designee that the health care\nservices furnished or proposed to be furnished to a covered person are:\na. Not medically necessary, as determined by the insurer or its\ndesignee; or\nb. Experimental or investigational, as determined by the insurer or its\ndesignee; and\n2. A coverage denial;\n(2) \"Authorized person\" means a pa rent, guardian, or other person authorized to act on\nbehalf of a covered person with respect to health care decisions;\n(3) \"Concurrent review\" means utilization review conducted during a covered person's\ncourse of treatment or hospital stay;\n(4) \"Coverage denial\" means a determination that a service, procedure, treatment, drug,\nsupply, or device is specifically limited or excluded under a covered person's health\nbenefit plan;\n(5) \"Covered person\" means a person covered under a health benefit plan;\n(6) \"External review\" means a review that is conducted by an independent review\nentity which meets specified criteria as established in KRS 304.17A -621, 304.17A-\n623, 304.17A-625, and 304.17A-627;\n(7) \"Health benefit plan\" has the same meaning as in KRS 304.17A-005, except that for\npurposes of KRS 304.17A -600 to 304.17A -633, the term includes short -term\ncoverage policies;\n(8) \"Independent review entity\" means an individual or organization certified by the\ndepartment to perform external reviews under KRS 304.17A -621, 304.17A-623,\n304.17A-625, and 304.17A-627;\n(9) \"Insurer\" means any of the following entities that issue or provide health benefit\nplans:\n(a) An insurance company;\n(b) Health maintenance organization;\n(c) Self-insurer or multiple employer welfare arrangemen t not exempt from state\nregulation by ERISA;\n(d) Provider-sponsored integrated health delivery network;\n(e) Self-insured employer-organized association;\n(f) Nonprofit hospital, medical-surgical, or health service corporation; or\n(g) Any other entity authorized to transact health insurance business in Kentucky;\n(10) \"Internal appeals process\" means a formal appeals process, as set forth in KRS\n304.17A-617, established and maintained by the insurer, its designee, or private\nreview agent;\n(11) \"Nationally recognized accreditation organization\":\n(a) Means a private nonprofit entity that:\n1. Sets national utilization review and internal appeal standards; and\n2. Conducts review of insurers, agents, or independent review entities for\nthe purpose of accreditation or certification; and\n(b) Shall include the Accreditation Association for Ambulatory Health Care\n(AAAHC), the National Committee for Quality Assurance (NCQA), the\nAmerican Accreditation Health Care Commission (URAC), the Joint\nCommission, or any other organization identified by the department;\n(12) \"Private review agent\" or \"agent\":\n(a) Means a person or entity performing utilization review that is either affiliated\nwith, under contract with, or acting on behalf of any insurer or other person\nproviding or ad ministering health benefits to citizens of this Commonwealth;\nand\n(b) Does not include an independent review entity that performs external reviews;\n(13) \"Prospective review\":\n(a) Means a utilization review that is conducted prior to the provision of health\ncare services; and\n(b) Includes any insurer's or agent's requirement that a covered person or provider\nnotify the insurer or agent prior to providing a health care service, inclu ding\nbut not limited to prior authorization, step therapy protocol, preadmission\nreview, pretreatment review, utilization, and case management;\n(14) \"Qualified personnel\" means licensed physician, registered nurse, licensed practical\nnurse, medical records technician, or other licensed medical personnel who through\ntraining and experience shall render consistent decisions based on the review\ncriteria;\n(15) \"Registration\" means an authorization issued by the department to an insurer or a\nprivate review agent to conduct utilization review;\n(16) \"Retrospective review\":\n(a) Means utilization review that is conducted after health care services have been\nprovided to a covered person; and\n(b) Does not include the review of a claim that is limited to an evaluation o f\nreimbursement levels, or adjudication of payment;\n(17) \"Urgent health care services\":\n(a) Means health care or treatment with respect to which the application of the\ntime periods for making a nonurgent determination:\n1. Could seriously jeopardize the life or health of the covered person or the\nability of the covered person to regain maximum function; or\n2. In the opinion of a physician with knowledge of the covered person's\nmedical condition, would subject the covered person to severe pain that\ncannot be adequately managed without the care or treatment that is the\nsubject of the utilization review; and\n(b) Includes all requests for hospitalization and outpatient surgery;\n(18) \"Utilization review\" means a review of the medical necessity and appropriateness of\nhospital resources and medical services given or proposed to be given to a covered\nperson for purposes of determining the availability of payment. Areas of review\ninclude concurrent, prospective, and retrospective review; and\n(19) \"Utilization review pl an\" means a description of the procedures governing\nutilization review activities performed by an insurer or a private review agent.","path":[],"source_url":"https://apps.legislature.ky.gov/law/statutes/statute.aspx?id=57341","current_through":"Includes enactments through the 2026 Regular Session","vintage":"09/05/2026","retrieved_at":"2026-09-05T20:57:47Z","sha256":"ffe69e15ad58021a9deb35c93f6cad4b9481472b61b1d57eba4d36822d225efd","source_id":"us-ky","stale":false,"prev":"us-ky/krs-304.17a-599","next":"us-ky/krs-304.17a-603"},"notice":"GroundRules: Original legal text. Not legal advice."}