{"data":{"id":"us-ky/krs-304.17a-606","jurisdiction":"us-ky","citation":"KRS 304.17A-606","heading":"Definitions for section -- Prior authorization exemption program --","body":"Program requirements and options.  (Effective January 1, 2028)\n(1) As used in this section:\n(a) \"Covered health care service\" means a health care service furnished or\nproposed to be furnished to a covered person that is specifically available or\nincluded as a covered benefit in the covered person's health benefit plan;\n(b) \"Electronic health record\" has the same meaning as in 42 U.S.C. sec. 17921,\nas amended;\n(c) \"Evaluation p eriod\" means a twelve (12) month period of time for which a\nhealth care provider's prior authorization experience is evaluated by an insurer\nor private review agent;\n(d) \"Health care provider\" has the same meaning as in KRS 304.17A -005, except\nfor purposes  of this section the term includes, if practicing independently,\nany:\n1. Licensed clinical alcohol and drug counselor licensed under KRS\nChapter 309;\n2. Licensed psychologist, licensed psychological practitioner, or certified\npsychologist with autonomous f unctioning licensed or certified under\nthe provisions of KRS Chapter 319;\n3. Licensed professional clinical counselor licensed under KRS Chapter\n335;\n4. Licensed marriage and family therapist licensed under KRS Chapter\n335;\n5. Licensed professional art therapist licensed under KRS Chapter 309; and\n6. Licensed clinical social worker licensed under KRS Chapter 335;\n(e) \"Health care provider group\" means two (2) or more health care providers that\nprovide health care services within an entity that shares a common:\n1. Group provider number; or\n2. Tax identification number;\n(f) \"Health care service\" has the same meaning as in KRS 304.17A -005, except\nfor purposes of this section the term:\n1. Includes procedures, treatments, and services rendered by a health care\nprovider as defined in this section; and\n2. Does not include the provision of prescription drugs;\n(g) \"Interoperability standards\" means the technical stan dards set forth in 45\nC.F.R. sec. 170.215, as amended;\n(h) \"Participating provider\":\n1. Means a health care provider that has entered into a participating\nprovider contract; and\n2. Includes a health care provider group if the insurer has elected to offer\nan exemption to the health care provider group under subsection (4)(b)2.\nof this section;\n(i) \"Participating provider contract\" means a contract between a health care\nprovider, either directly or through a health care provider group, and an\ninsurer for the provision of health care services under a health benefit plan;\n(j) \"Utilization\" means the number of claims submitted for a particular health\ncare service under a health benefit plan by a participating provider; and\n(k) \"Value-based care agreement\" means a  contractual agreement between a\nhealth care provider, either directly or through a health care provider group,\nand an insurer that:\n1. Incentivizes or rewards the provider based on one (1) or more of the\nfollowing:\na. Quality of care;\nb. Safety;\nc. Patient outcomes;\nd. Efficiency;\ne. Cost reduction; or\nf. Other factors; and\n2. May, but is not required to, include shared financial risk and rewards\nbased on performance metrics.\n(2) An insurer or its private review agent shall not require a covered person, au thorized\nperson, or participating provider to obtain a prior authorization for a particular\nhealth care service under a health benefit plan if, at the time the health care service\nwas provided, the provider had a prior authorization exemption for that part icular\nhealth care service under a program offered under subsection (3) of this section.\n(3) Every insurer shall offer a program under which a participating provider may\nqualify for an exemption from the requirement to obtain prior authorization for any\ncovered health care service that requires prior authorization.\n(4) The program offered under subsection (3) of this section:\n(a) Shall:\n1. Provide that a participat ing provider, for an evaluation period\nestablished by the insurer or private review agent, receive a prior\nauthorization exemption for a particular health care service if, during the\nprevious evaluation period, the provider met program terms and\nconditions established by the insurer or private review agent that are not\nin violation of this section;\n2. Not condition a prior authorization exemption upon the provider\nexceeding a ninety -three percent (93%) approval rate for prior\nauthorization requests submitte d by the provider for that health care\nservice during an evaluation period;\n3. Require the insurer or its private review agent to evaluate, on an annual\nbasis, whether a participating provider qualifies to receive a prior\nauthorization exemption for each c overed health care service for which\nthe insurer requires prior authorization;\n4. Require each annual evaluation required under subparagraph 3. of this\nparagraph to be conducted on:\na. For participating provider contracts that have a performance period\nof one (1) year, the contract's renewal date; or\nb. For participating provider contracts that have a performance period\nof greater than one (1) year, the annual anniversary date of the\ncontract renewal;\n5. Require an insurer or its private review agent to notify each participating\nprovider that qualifies for a prior authorization exemption within thirty\n(30) days after conducting the annual evaluation required under\nsubparagraph 3. of this paragraph;\n6. Require an insurer or its private review agent to make av ailable to a\nhealth care provider during the contracting process the requirements that\nthe provider must meet to participate in the program; and\n7. Comply with any administrative regulation promulgated under KRS\n304.2-110 for or as an aid to the effectuation of this section; and\n(b) May:\n1. Offer a prior authorization exemption for any prescription drug;\n2. Offer a prior authorization exemption to a health care provider group in\nlieu of each participating provider practicing within a health care\nprovider group;\n3. Condition a participating provider's eligibility to participate in the\nprogram on the provider satisfying one (1) or more of the following:\na. The provider has entered into, either directly or through a health\ncare provider group, a value -based car e agreement with the\ninsurer;\nb. The provider has been a participating provider for a minimum\nperiod of time established by the insurer or private review agent,\nexcept an established minimum period of time shall not be more\nthan one (1) year; or\nc. The provider:\ni. Complies with interoperability standards; and\nii. Has entered into, either directly or through a health care\nprovider group, an electronic health record access agreement\nwith the insurer or private review agent;\n4. Provide that a participating pr ovider shall not qualify for a prior\nauthorization exemption for any particular health care service unless the\nprovider's utilization for that health care service during the previous\nevaluation period meets any utilization requirement established by the\ninsurer or private review agent, except an established utilization\nrequirement shall not:\na. Require a minimum utilization of more than twenty-four (24); or\nb. Impose a maximum utilization of less than one hundred ten\npercent (110%) of the participating prov ider's utilization for that\nparticular health care service during the previous evaluation\nperiod; and\n5. Provide that an insurer or its private review agent may revoke a\nparticipating provider's prior authorization exemption for any particular\nhealth care service, or suspend or revoke a participating provider's\nparticipation in the program, if:\na. The insurer or private review agent has evidence that the provider\nhas engaged in fraud or abuse; or\nb. The provider's utilization meets or exceeds a maximum utilization\nimposed under subparagraph 4.b. of this paragraph.\n(5) If an insurer or its private review agent determines that a participating provider is\neligible to participate in the program offered un der subsection (3) of this section,\nthe insurer or private review agent shall send a notice to the provider that includes:\n(a) A statement that the provider is eligible to participate in the program; and\n(b) A list of each health care service that is subje ct to the elimination of prior\nauthorization requirements under the program.\n(6) For all forms and notices sent to a participating provider in accordance with this\nsection, or any administrative regulations promulgated under KRS 304.2 -110 for or\nas an aid to the effectuation of this section, the insurer or its private review agent\nshall:\n(a) Provide a process for the provider to designate and update the provider's\npreferred manner for receiving the forms and notices; and\n(b) Send the forms and notices to th e provider in the manner designated under\nparagraph (a) of this subsection.\n(7) This section shall not be construed to:\n(a) Prevent an insurer or its private review agent from requesting a health care\nprovider to provide additional information about a heal th care service\nrendered to a covered person; or\n(b) Require coverage of a noncovered health care service under a covered\nperson's health benefit plan.","path":[],"source_url":"https://apps.legislature.ky.gov/law/statutes/statute.aspx?id=58325","current_through":"Includes enactments through the 2026 Regular Session","vintage":"09/05/2026","retrieved_at":"2026-09-05T20:57:47Z","sha256":"9cdbbdb3e6329288506dd2af9ba083c8db33cef634fe8444e46edfb03df927ea","source_id":"us-ky","stale":false,"prev":"us-ky/krs-304.17a-605","next":"us-ky/krs-304.17a-6061"},"notice":"GroundRules: Original legal text. Not legal advice."}