{"data":{"id":"us-ky/krs-304.17a-609","jurisdiction":"us-ky","citation":"KRS 304.17A-609","heading":"Emergency administrative regulations governing utilization review","body":"and internal appeal to be promulgated by the department.\nThe department shall promulgate emergency administrative regulations regarding\nutilization review and internal appeal, inclu ding the specification of information required\nof insurers and private review agents which shall, at a minimum, include:\n(1) A utilization review plan that contains all information utilized for conducting\npreadmission, admission, readmission review, preaut horization, continued stay\nauthorization, and retrospective review and which, for each type of review,\nincludes:\n(a) Utilization review policies and procedures to evaluate proposed or delivered\nmedical services;\n(b) Time frames for review;\n(c) A written summary describing the review process and required forms;\n(d) Documentation that actively practicing providers with appropriate\nqualifications are involved in the development or adoption of utilization\nreview criteria relating to specialty and subspecialty areas;\n(e) Descriptions and names of review criteria upon which utilization review\ndecisions are based; and\n(f) Additional standards, if any, for the consideration of special circumstances;\n(2) The type and qualifications of the personnel either employed or  under contract to\nperform utilization review;\n(3) Assurance that a toll -free line will be provided that covered persons, authorized\npersons, and providers may use to contact the insurer or private review agent;\n(4) The policies and procedures to ensure th at a representative of the insurer or private\nreview agent shall be reasonably accessible to covered persons, authorized persons,\nand providers at least forty (40) hours per week during normal business hours;\n(5) The policies and procedures to ensure that all applicable state and federal laws to\nprotect the confidentiality of individual medical records are followed;\n(6) A copy of the materials designed to inform covered persons, authorized persons,\nand providers of the toll -free number and the requirements of the utilization review\nplan;\n(7) A list of the entities for which the private review agent is performing utilization\nreview in this state; and\n(8) Evidence of compliance or the ability to comply with the requirements and\nprocedures established regarding utilization review and the administrative\nregulations promulgated thereunder.\n(9) In lieu of disclosing information specified in subsection (1) of th is section, an\ninsurer or private review agent may submit to the department evidence of\naccreditation or certification, if any, with a nationally recognized accreditation\norganization that oversees the information described in subsections (1) to (8) of thi s\nsection, provided that the department may still require the information in subsection\n(8) of this section or other information to demonstrate compliance with the\nrequirements of this section and KRS 304.17A -600, 304.17A -607, 304.17A -613,\n304.17A-617, 304.17A-623, and 304.17A -625 not covered by the standards of the\nnationally recognized accreditation organization, as well as basic information\nnecessary for the department to contact the insurer or private review agent. Nothing\nin this subsection shall be construed to prohibit or in any way limit the department's\nauthority to require the submission of information specified in subsections (1) to (8)\nof this section or any other information the department deems necessary for\npurposes of investigating a complain t that the insurer or private review agent is not\nin compliance with KRS 304.17A-600 to 304.17A-633.","path":[],"source_url":"https://apps.legislature.ky.gov/law/statutes/statute.aspx?id=17454","current_through":"Includes enactments through the 2026 Regular Session","vintage":"09/05/2026","retrieved_at":"2026-09-05T20:57:47Z","sha256":"8b5b8f36a44fb53a96746bae47fa506c07d983b312d7cea5713c57ffa834b6d1","source_id":"us-ky","stale":false,"prev":"us-ky/krs-304.17a-607","next":"us-ky/krs-304.17a-611"},"notice":"GroundRules: Original legal text. Not legal advice."}