{"data":{"id":"us-ky/krs-304.17a-607","jurisdiction":"us-ky","citation":"KRS 304.17A-607","heading":"Duties of insurer or private review agent performing utilization","body":"reviews -- Requirement for registration -- Consequences of insurer's failure to\nmake timely utilization review determination -- Requirement that insurer or\nprivate review agent submit changes to the department -- Requirement that\nprivate review agent provide timely notice of entities for whom it is providing\nreview.\n(1) An insurer or private review agent shall not provide or perform utilization reviews\nwithout being registered with the department.\n(2) A registered insurer or private review agent shall:\n(a) Have available the services of sufficient numbers of registered nurses,\nmedical records technicians, or similarly qualified persons supported by\nlicensed physician s with access to consultation with other appropriate\nphysicians to carry out its utilization review activities;\n(b) Ensure that for the provision of utilization review services, only licensed\nphysicians, who are of the same or similar specialty and subspec ialty, when\npossible, as the ordering provider, shall:\n1. Make a utilization review decision to:\na. Deny, reduce, limit, or terminate a health care benefit; or\nb. Deny, or reduce payment for, a health care service because that\nservice is not medically nece ssary, experimental, or\ninvestigational;\nexcept in the case of a health care service rendered by a chiropractor or\noptometrist where the denial shall be made respectively by a\nchiropractor or optometrist duly licensed in Kentucky; and\n2. Supervise qualified personnel conducting case reviews;\n(c) Have available the services of sufficient numbers of practicing physicians in\nappropriate specialty areas to assure the adequate review of medical and\nsurgical specialty and subspecialty cases;\n(d) Not disclose or publish individual medical records or any other confidential\nmedical information in the performance of utilization review activities except\nas provided in the Health Insurance Portability and Accountability Act,\nSubtitle F, secs. 261 to 264 and 45 C.F.R. pts. 160 to 164 and other applicable\nlaws and administrative regulations;\n(e) Provide a toll-free telephone line for covered persons, authorized persons, and\nproviders to contact the insurer or private review agent and be accessible to\ncovered persons, authorized persons, and providers for forty (40) hours a\nweek during normal business hours in this state;\n(f) Where an insurer, its agent, or private review agent provides or performs\nutilization review, be available to conduct utilization rev iew during normal\nbusiness hours and extended hours in this state on Monday and Friday through\n6:00 p.m., including federal holidays;\n(g) Provide decisions to covered persons, authorized persons, and all providers on\nappeals of adverse benefit determinatio ns of the insurer or private review\nagent, in accordance with this section and administrative regulations\npromulgated in accordance with KRS 304.17A-609;\n(h) Except for retrospective review of an emergency admission where the covered\nperson remains hospita lized at the time the review request is made, which\nshall be considered a concurrent review, or as otherwise provided in this\nsubtitle, provide a utilization review decision in accordance with the\ntimeframes in paragraph (i) of this subsection and 29 C.F.R . pt. 2560,\nincluding written notice of the decision;\n(i) 1. Render a utilization review decision concerning urgent health care\nservices, and notify the covered person, authorized person, or provider\nof that decision no later than twenty -four (24) hours af ter obtaining all\nnecessary information to make the utilization review decision; and\n2. If the insurer or agent requires a utilization review decision of nonurgent\nhealth care services, render a utilization review decision and notify the\ncovered person, au thorized person, or provider of the decision within\nfive (5) days of obtaining all necessary information to make the\nutilization review decision.\nFor purposes of this paragraph, \"necessary information\" is limited to:\na. The results of any face-to-face clinical evaluation;\nb. Any second opinion that may be required; and\nc. Any other information determined by the department to be\nnecessary to making a utilization review determination;\n(j) 1. Provide written notice of review decisions to the covered person,\nauthorized person, and providers.\n2. The written notice may be provided in an electronic format, including\nemail or facsimile, if the covered person, authorized person, or provider\nhas agreed in advance in writing to receive the notices electronically.\n3. An insurer or agent that denies a step therapy exception, as defined in\nKRS 304.17A -163, or denies coverage or reduces payment for a\ntreatment, procedure, drug that requires prior approval, or device shall\ninclude in the written notice:\na. A statement of th e specific medical and scientific reasons for\ndenial or reduction of payment or identifying that provision of the\nschedule of benefits or exclusions that demonstrates that coverage\nis not available;\nb. The title of the reviewer making the decision, except that a written\nnotice provided to a provider shall also include, if applicable, the\nmedical license number of the reviewer making the decision;\nc. Except for retrospective review, a description of alternative\nbenefits, services, or supplies covered by the health benefit plan, if\nany; and\nd. Instructions for initiating or complying with the insurer's internal\nappeal procedure, as set forth in KRS 304.17A -617, stating, at a\nminimum:\ni. Whether the appeal shall be in writing;\nii. Any specific filing procedures, including any applicable time\nlimitations or schedules; and\niii. The position and phone number of a contact person who can\nprovide additional information;\n(k) Afford participating physicians an opportunity to review and comment on all\nmedical and surgica l and emergency room protocols, respectively, of the\ninsurer and afford other participating providers an opportunity to review and\ncomment on all of the insurer's protocols that are within the provider's legally\nauthorized scope of practice; and\n(l) Comply with its own policies and procedures on file with the department or, if\naccredited or certified by a nationally recognized accrediting entity, comply\nwith the utilization review standards of that accrediting entity where they are\ncomparable and do not conflict with state law.\n(3) (a) The insurer's or private review agent's failure to make a determination and\nprovide written notice within the time frames set forth in this section shall be\ndeemed to be a prior authorization for the health care services or benefits\nsubject to the review.\n(b) This subsection shall not apply where the failure to make the determination or\nprovide the notice results from circumstances which are documented to be\nbeyond the insurer's control.\n(4) (a) An insurer or private review agent shall submit a copy of any changes to its\nutilization review policies or procedures to the department.\n(b) No change to utilization review policies and procedures shall be effective or\nused until after it has been filed with and approved by the commissioner.\n(5) (a) A private review  agent shall provide to the department the names of the\nentities for which the private review agent is performing utilization review in\nthis state.\n(b) Notice shall be provided to the department within thirty (30) days of any\nchange.","path":[],"source_url":"https://apps.legislature.ky.gov/law/statutes/statute.aspx?id=57342","current_through":"Includes enactments through the 2026 Regular Session","vintage":"09/05/2026","retrieved_at":"2026-09-05T20:57:47Z","sha256":"76471c8727ab1b898b65c1efc430a4b4232199f7658e8c2f7c023edb865bbb8f","source_id":"us-ky","stale":false,"prev":"us-ky/krs-304.17a-6061","next":"us-ky/krs-304.17a-609"},"notice":"GroundRules: Original legal text. Not legal advice."}