{"data":{"id":"us-ky/krs-304.17a-617","jurisdiction":"us-ky","citation":"KRS 304.17A-617","heading":"Internal appeals process -- Procedures -- Review of coverage denials.","body":"(1) (a) Every insurer shall have an internal appeal process for adverse benefit\ndeterminations that is:\n1. Utilized by the insurer or its designee, consistent w ith this section and\nKRS 304.17A-619; and\n2. Disclosed to covered persons in accordance with KRS 304.17A -\n505(1)(g).\n(b) An insurer shall disclose the availability of the internal appeal process to the\ncovered person in the insured's timely notice of an adv erse benefit\ndetermination which meets the requirements in KRS 304.17A-607(2)(j).\n(c) Where a coverage denial is involved, in addition to stating the reason for the\ncoverage denial, the required notice shall contain instructions for filing a\nrequest for internal appeal.\n(2) The internal appeals process may be initiated by the covered person, an authorized\nperson, or a provider acting on behalf of the covered person.\n(3) The internal appeals process shall include adequate and reasonable procedures for\nreview and resolution of appeals concerning adverse benefit determinations,\nincluding procedures for reviewing appeals from covered persons whose medical\nconditions require expedited review.\n(4) At a minimum, the p rocedures required under subsection (3) of this section shall\ninclude the following:\n(a) Except as provided in KRS 304.17A -163, insurers or their designees shall\nprovide decisions to covered persons, authorized persons, and providers on\ninternal appeals:\n1. Within thirty (30) days of receipt of the request for internal appeal,\nexcept as provided in subparagraph 2. of this paragraph; or\n2. Not later than three (3) business days after receipt of a request for an\nexpedited appeal of an adverse benefit determin ation. An expedited\nappeal is deemed necessary when a covered person is hospitalized or, in\nthe opinion of the treating provider, review under a standard time frame\ncould, in the absence of immediate medical attention, result in any of the\nfollowing:\na. Placing the health of the covered person or, with respect to a\npregnant woman, the health of the covered person or the unborn\nchild in serious jeopardy;\nb. Serious impairment to bodily functions; or\nc. Serious dysfunction of a bodily organ or part;\n(b) Internal appeal of an adverse benefit determination, other than a coverage\ndenial, shall only be conducted by a licensed physician who did not\nparticipate in the initial review and denial, except in the case of a review\ninvolving a medical or surgical specialty  or subspecialty, the insurer or agent\nshall, upon request by a covered person, authorized person, or provider, utilize\na board -eligible or certified physician in the appropriate specialty or\nsubspecialty area to conduct the internal appeal;\n(c) Those portions of the medical record that are relevant to the internal appeal, if\nauthorized by the covered person and in accordance with state or federal law,\nshall be considered and providers given the opportunity to present additional\ninformation; and\n(d) In addition to any previous notice required under KRS 304.17A-607(2)(j), and\nto facilitate expeditious handling of a request for external review or review of\na coverage denial under subsection (5) of this section, an insurer or agent that\ndenies, limits, reduces,  or terminates coverage for a service, treatment,\nprocedure, drug, supply, or device for a covered person shall provide the\ncovered person, authorized person, or provider acting on behalf of the covered\nperson with an internal appeal determination letter that includes:\n1. A statement of the specific medical and scientific reasons for denying\ncoverage or identifying that provision of the schedule of benefits or\nexclusions that demonstrates that coverage is not available;\n2. As applicable, the state of licens ure and the title of the person making\nthe decision, except that an internal appeal determination letter provided\nto a provider acting on behalf of the covered person shall also include\nthe medical license number of the person making the decision;\n3. Except for retrospective review, a description of alternative benefits,\nservices, or supplies covered by the health benefit plan, if any; and\n4. Instructions for:\na. Initiating an external review; or\nb. For coverage denials, filing a request for review with th e\ndepartment under subsection (5) of this section.\n(5) (a) The department shall establish and maintain a system for receiving and\nreviewing requests for review of coverage denials from covered persons,\nauthorized persons, and providers.\n(b) For purposes of  this subsection, \"coverage denials\" shall not include\nsubsequent denials arising from an adverse benefit determination that is not a\ncoverage denial.\n(c) On receipt of a written request for review of a coverage denial from a covered\nperson, authorized person, or provider, the department shall:\n1. Notify the insurer that issued the denial of the request for review; and\n2. Call for the insurer to respond to the department regarding the request\nfor review within ten (10) business days of receipt of notice to the\ninsurer.\n(d) Within ten (10) business days of receiving the notice of the request for review\nfrom the department, the insurer shall provide to the department the following\ninformation:\n1. Confirmation as to whether the person who received or sought the\nservice, procedure, treatment, drug, supply, or device for which\ncoverage was denied was a covered person under a health benefit plan\nissued by the insurer on the date the service, procedure, treatment, drug,\nsupply, or device was sought or denied;\n2. Confirmation as to whether the covered person, authorized person, or\nprovider has exhausted his or her rights under the insurer's internal\nappeal process under this section; and\n3. The reason for the coverage denial, including the specific limitation or\nexclusion of the health benefit plan demonstrating that coverage is not\navailable.\n(e) In addition to the information described  in paragraph (d) of this subsection,\nthe insurer and the covered person, authorized person, or provider shall\nprovide to the department any information requested by the department that is\ngermane to its review.\n(f) 1. On the receipt of the information des cribed in paragraphs (d) and (e) of\nthis subsection, unless the department is not able to do so because\nmaking a determination requires resolution of a medical issue, it shall\ndetermine whether the service, procedure, treatment, drug, supply, or\ndevice is specifically limited or excluded under the terms of the covered\nperson's health benefit plan.\n2. If the department determines that the service, procedure, treatment,\ndrug, supply, or device is not specifically limited or excluded, it shall so\nnotify the in surer, and the insurer shall either cover the service,\nprocedure, treatment, drug, supply, or device or afford the covered\nperson an opportunity for external review, where the conditions\nprecedent to the review are present.\n3. If the department notifies th e insurer that the service, procedure,\ntreatment, drug, supply, or device is specifically limited or excluded in\nthe health benefit plan, the insurer is not required to cover the service,\nprocedure, treatment, drug, supply, or device or afford the covered\nperson an external review.\n(g) An insurer shall be required to cover the service, procedure, treatment, drug,\nsupply, or device that was denied or provide notification of the right to\nexternal review in accordance with paragraph (f) of this subsection whet her\nthe covered person has disenrolled or remains enrolled with the insurer.\n(h) If the covered person has disenrolled with the insurer, the insurer shall only be\nrequired to provide the service, procedure, treatment, drug, supply, or device\nthat was denie d for a period not to exceed thirty (30) days or provide the\ncovered person the opportunity for external review.","path":[],"source_url":"https://apps.legislature.ky.gov/law/statutes/statute.aspx?id=57343","current_through":"Includes enactments through the 2026 Regular Session","vintage":"09/05/2026","retrieved_at":"2026-09-05T20:57:47Z","sha256":"b461b710e53854abdce171bf016626edec2acfdf8e1f61fdaacbb60d5cd3fa46","source_id":"us-ky","stale":false,"prev":"us-ky/krs-304.17a-615","next":"us-ky/krs-304.17a-619"},"notice":"GroundRules: Original legal text. Not legal advice."}