{"data":{"id":"us-ky/krs-304.17a-623","jurisdiction":"us-ky","citation":"KRS 304.17A-623","heading":"External review of adverse benefit determination -- Who may request","body":"-- Criteria for review -- Fee -- Conditions under which covered person not\nentitled to review -- Resolution of disputes -- Confidentiality -- Expedited\nexternal review.\n(1) (a) Every insurer shall have an external review process to be utilized by the\ninsurer or its designee, consistent with this section and which shall be\ndisclosed to covered persons in accordance with KRS 304.17A-505(1)(g).\n(b) An insurer, its designee, or agent shall disclose the availability of the external\nreview process to the covered person in the insured's timely notice of an\nadverse benefit determination, other than a coverage denial, as set forth in\nKRS 304.17A -607(2)(j) and in the denial lette r required in KRS 304.17A -\n617(1) and (4)(d).\n(2) A covered person, an authorized person, or a provider acting on behalf of and with\nthe consent of the covered person, may request an external review of an adverse\nbenefit determination, other than a coverage  denial, rendered by an insurer, its\ndesignee, or agent.\n(3) Except as provided in KRS 304.17A -163, the insurer shall provide an external\nreview if the following criteria are met:\n(a) The insurer, its designee, or agent has rendered an adverse benefit\ndetermination, other than a coverage denial;\n(b) The covered person has completed the insurer's internal appeal process or the\ninsurer has failed to make a timely determination or notification as set forth in\nKRS 304.17A -619(2). The insurer and the covered per son may, however,\njointly agree to waive the internal appeal requirement;\n(c) The covered person was enrolled in the health benefit plan on the date of\nservice or, if a prospective denial, the covered person was enrolled and\neligible to receive covered ben efits under the health benefit plan on the date\nthe proposed health care service was requested; and\n(d) The entire course of treatment or service will cost the covered person at least\none hundred dollars ($100) if the covered person had no insurance.\n(4) (a) The covered person, an authorized person, or a provider with consent of the\ncovered person shall submit a request for external review to the insurer within\nsixty (60) days, except as set forth in KRS 304.17A -619(1), of receiving\nnotice that an adverse benefit determination, other than a coverage denial, has\nbeen timely rendered under the insurer's internal appeal process.\n(b) As part of the request, the covered person shall provide to the insurer or its\ndesignee written consent authorizing the indep endent review entity to obtain\nall necessary medical records from both the insurer and any provider utilized\nfor review purposes regarding the determination.\n(5) (a) The covered person shall be assessed a one (1) time filing fee of twenty -five\ndollars ($25) that:\n1. Shall be paid to the independent review entity; and\n2. May be waived if the independent review entity determines that the fee\ncreates a financial hardship on the covered person.\n(b) The fee shall be refunded if the independent review entity finds in favor of the\ncovered person.\n(6) A covered person shall not be afforded an external review if:\n(a) The subject of the covered person's external review request has previously\ngone through the external review process and the independent review entity\nfound in favor of the insurer; and\n(b) No relevant new clinical information has been submitted to the insurer since\nthe independent review entity found in favor of the insurer.\n(7) (a) The department shall establish a system for each insurer to be assigned a n\nindependent review entity for external reviews.\n(b) The system established by the department shall:\n1. Be prospective; and\n2. Require insurers to utilize independent review entities on a rotating basis\nso that an insurer does not have the same independen t review entity for\ntwo (2) consecutive external reviews.\n(c) The department shall contract with no less than two (2) independent review\nentities.\n(8) (a) If a dispute arises between an insurer and a covered person regarding the\ncovered person's right to a n external review, the covered person may file a\ncomplaint with the department.\n(b) Within five (5) days of receipt of the complaint, the department:\n1. Shall render a decision; and\n2. May direct the insurer to submit the dispute to an independent review\nentity for an external review if it finds all of the requirements of\nsubsection (3) of this section have been met.\n(c) The complaint process established in this section shall:\n1. Be separate and distinct from, and in no way limit, other grievance or\ncomplaint processes available to consumers under other provisions of\nthe Kentucky Revised Statutes or duly promulgated administrative\nregulations; and\n2. Not limit, alter, or supplant the mechanisms for appealing coverage\ndenials established in KRS 304.17A-617.\n(9) The external review process shall be confidential and shall not be subject to KRS\n61.805 to 61.850 and KRS 61.870 to 61.884.\n(10) External reviews shall be conducted in an expedited manner by the independent\nreview entity if:\n(a) The covered person is hospitalized; or\n(b) In the opinion of the treating provider, review under the standard time frame\ncould, in the absence of immediate medical attention, result in any of the\nfollowing:\n1. Placing the health of the covered person or, with respect to a pregnant\nwoman, the health of the covered person or her unborn child in serious\njeopardy;\n2. Serious impairment to bodily functions; or\n3. Serious dysfunction of a bodily organ or part.\n(11) Requests for expedited external review shall be forwarded by the insurer to the\nindependent review entity within twenty-four (24) hours of receipt by the insurer.\n(12) (a) For expedited external review, a determination shall be made by the\nindependent review entity within twenty -four (24) hours from the receipt of\nall information required from the insurer.\n(b) An extension of up to twenty -four (24) hours may be allowed if the covered\nperson and the insurer or its designee agree.\n(c) The insurer or its designe e shall provide notice to the independent review\nentity and to the covered person, by same -day communication, that the\nexternal review request has been assigned to an independent review entity for\nexpedited review.\n(13) (a) External reviews which are not e xpedited shall be conducted by the\nindependent review entity and a determination made within twenty -one (21)\ncalendar days from the receipt of all information required from the insurer.\n(b) An extension of up to fourteen (14) calendar days may be allowed i f the\ncovered person and the insurer are in agreement.","path":[],"source_url":"https://apps.legislature.ky.gov/law/statutes/statute.aspx?id=57346","current_through":"Includes enactments through the 2026 Regular Session","vintage":"09/05/2026","retrieved_at":"2026-09-05T20:57:47Z","sha256":"0bc59ba2a69c04f4335d58d8a2f5e669ce86ea842d86821c9bfd037d5b06a43a","source_id":"us-ky","stale":false,"prev":"us-ky/krs-304.17a-621","next":"us-ky/krs-304.17a-625"},"notice":"GroundRules: Original legal text. Not legal advice."}