{"data":{"id":"us-ky/krs-304.17a-625","jurisdiction":"us-ky","citation":"KRS 304.17A-625","heading":"Factors to be considered by independent review entity conducting","body":"external review -- Basis for decision -- Insurer's responsibilities -- Contents,\nadmissibility, and effect of decision -- Consequence of insurer's failure to\nprovide coverage -- Liability -- Written complaints.\n(1) In making its decision, an independent review entity conducting the external review\nshall take into account all of the following:\n(a) Information submitted by the insurer, the covered person, the authorized\nperson, and the covered person's provider, including the following:\n1. The covered person's medical records;\n2. The standards, criteria, and clinical rationale used by the insurer to make\nits decision; and\n3. The insurer's health benefit plan;\n(b) Findings, studi es, research, and other relevant documents of government\nagencies and nationally recognized organizations, including the National\nInstitutes of Health, or any board recognized by the National Institutes of\nHealth, the National Cancer Institute, the Nationa l Academy of Sciences, and\nthe United States Food and Drug Administration, the Centers for Medicare \u0026\nMedicaid Services of the United States Department of Health and Human\nServices, and the Agency for Health Care Research and Quality; and\n(c) Relevant findings in peer -reviewed medical or scientific literature, published\nopinions of nationally recognized medical specialists, and clinical guidelines\nadopted by relevant national medical societies.\n(2) (a) The independent review entity shall base its decision o n the information\nsubmitted under subsection (1) of this section.\n(b) In making its decision, the independent review entity shall consider safety,\nappropriateness, and cost effectiveness.\n(3) (a) The insurer shall provide any coverage determined by the independent review\nentity to be medically necessary.\n(b) The independent review entity shall not be permitted to allow coverage for a\nservice, procedure, treatment, drug, supply, or device that is specifically\nlimited or excluded by the insurer in its health benefit plan.\n(c) The decision shall apply only to the individual cove red person's external\nreview.\n(4) Nothing in this section shall be construed as requiring an insurer to provide\ncoverage for out of network services, procedures, or tests, except as set forth in\nKRS 304.17A-515(1)(c) and 304.17A-550.\n(5) The insurer shall be responsible for the cost of the external review.\n(6) The independent review entity shall provide to the covered person, treating\nprovider, insurer, and the department a decision which shall include:\n(a) The findings for either the insurer or covered per son regarding each issue\nunder review;\n(b) The proposed service, procedure, treatment, drug, device, or supply for which\nthe review was performed;\n(c) The relevant provisions in the insurer's health benefit plan and how applied;\nand\n(d) The relevant provis ions of any nationally recognized and peer -reviewed\nmedical or scientific documents used in the external review.\n(7) The decision of the independent review entity shall not be made solely for the\nconvenience of the insurer, the covered person, or the provider.\n(8) (a) Consistent with the rules of evidence, a written decision prepared by an\nindependent review entity shall be admissible in any civil action related to the\ninsurer's determination.\n(b) The independent review entity's decision shall be presumed t o be a\nscientifically valid and accurate description of the state of medical knowledge\nat the time it was written.\n(9) (a) The decision of the independent review entity shall be binding on the insurer\nwith respect to that covered person.\n(b) Failure of the  insurer to provide coverage as required by the independent\nreview entity shall:\n1. Be a violation of the insurance code of a nature sufficient to warrant the\ncommissioner revoking or suspending the insurer's license or certificate\nof authority; and\n2. Constitute an unfair claims settlement practice as set forth in KRS\n304.12-230.\n(10) (a) Failure to provide coverage as required by the independent review entity shall\nalso:\n1. Subject the insurer to the provisions of KRS 304.99 -010 and 304.99 -\n020; and\n2. Require the insurer to pay the claim that was the subject of the external\nreview, without need for the covered person or authorized person to\nfurther establish a right as to the payment amount.\n(b) Reasonable attorney's fees associated with the actions of the insured necessary\nto collect amounts owed the covered person shall be assessed against and\nborne by the insurer.\n(11) The insurer shall implement the decision of the independent review entity whether\nthe covered person has disenrolled or remains enrolled with the insurer.\n(12) If the covered person has been disenrolled with the insurer, the insurer shall only be\nrequired to provide the treatment, procedure, service, drug, supply, or device that\nwas previously denied by the insurer, its agent, or designee a nd later approved by\nthe independent review entity for a period not to exceed thirty (30) days.\n(13) Within thirty (30) days of the decision in favor of the covered person by the\nindependent review entity, the insurer shall provide written notification to the\ndepartment that the decision has been implemented in accordance with this section.\n(14) (a) An independent review entity and any medical specialist the entity utilizes in\nconducting an external review shall not be liable in damages in a civil action\nfor injury, death, or loss to person or property and is not subject to\nprofessional disciplinary a ction for making, in good faith, any finding,\nconclusion, or determination required to complete the external review.\n(b) This subsection does not grant immunity from civil liability or professional\ndisciplinary action to an independent review entity or medical specialist for an\naction that is outside the scope of authority granted in KRS 304.17A -621,\n304.17A-623, and 304.17A-625.\n(15) Nothing in KRS 304.17A -600 to 304.17A -633 shall be construed to create a cause\nof action against any of the following:\n(a) An employer that provides health care benefits to employees through a health\nbenefit plan;\n(b) A medical expert, private review agent, or independent review entity that\nparticipates in the utilization review, internal appeal, or external review\naddressed in KRS 304.17A-600 to 304.17A-633; or\n(c) An insurer or provider acting in good faith and in accordance with any\nfinding, conclusion, or determination of an Independent Review Entity acting\nwithin the scope of authority set forth in KRS 304.17A -621, 304.17A -623,\nand 304.17A-625.\n(16) (a) The covered person, insurer, or provider in the external review may submit\nwritten complaints to the department regarding any independent review\nentity's actions believed to be an inappropriate application of the requirements\nset forth in KRS 304.17A-621, 304.17A-623, and 304.17A-625.\n(b) The department shall promptly review the complaint, and if the department\ndetermines that the actions of the independent review entity were\ninappropriate, the department shall take corrective  measures, including\ndecertification or suspension of the independent review entity from further\nparticipation in external reviews.\n(c) The department's actions shall be subject to the powers and administrative\nprocedures set forth in Subtitle 17A of KRS Chapter 304.","path":[],"source_url":"https://apps.legislature.ky.gov/law/statutes/statute.aspx?id=57347","current_through":"Includes enactments through the 2026 Regular Session","vintage":"09/05/2026","retrieved_at":"2026-09-05T20:57:47Z","sha256":"f6677fbd56da831c7649e2c62716074daf9d5b85a866345d35eb38eccd702e67","source_id":"us-ky","stale":false,"prev":"us-ky/krs-304.17a-623","next":"us-ky/krs-304.17a-627"},"notice":"GroundRules: Original legal text. Not legal advice."}