{"data":{"id":"us-ky/krs-304.17a-627","jurisdiction":"us-ky","citation":"KRS 304.17A-627","heading":"Certification as independent review entity -- Requirements and","body":"restrictions.\n(1) To be certified as an independent review entity under this chapter, an organization\nshall submit to the department an application on a form required by the department .\nThe application shall include the following:\n(a) The name of each stockholder or owner of more than five percent (5%) of any\nstock or options for an applicant;\n(b) The name of any holder of bonds or notes of the applicant that exceeds one\nhundred thousand dollars ($100,000);\n(c) The name and type of business of each corporation or other organization that\nthe applicant controls or with which it is affiliated and the nature and extent of\nthe affiliation or control;\n(d) The name and a biographical sketch of each director, officer, and executive of\nthe applicant and any entity listed under paragraph (c) of this subsection and a\ndescription of any relationship the named individual has with an insurer as\ndefined in KRS 304.17A-600 or a provider of health care services;\n(e) The percentage of the applicant's revenues that are anticipated to be derived\nfrom independent reviews;\n(f) A description of the minimum qualifications employed by the independent\nreview entity to select health care professionals to perform ext ernal review,\ntheir areas of expertise, and the medical credentials of the health care\nprofessionals currently available to perform external reviews; and\n(g) The procedures to be used by the independent review entity in making review\ndeterminations.\n(2) If at any time there is a material change in the information included in the\napplication, provided for in subsection (1) of this section, the independent review\nentity shall submit updated information to the department.\n(3) An independent review entity shall  not be a subsidiary of, or in any way affiliated\nwith, or owned, or controlled by an insurer or a trade or professional association of\npayors.\n(4) An independent review entity shall not be a subsidiary of, or in any way affiliated\nwith, or owned, or controlled by a trade or professional association of providers.\n(5) Health care professionals who are acting as reviewers for the independent review\nentity shall hold in good standing a nonrestricted license in a state of the United\nStates.\n(6) Health care prof essionals who are acting as reviewers for the independent review\nentity shall hold a current certification by a recognized American medical specialty\nboard or other recognized health care professional boards in the area appropriate to\nthe subject of the re view, be a specialist in the treatment of the covered person's\nmedical condition under review, and have actual clinical experience in that medical\ncondition.\n(7) The independent review entity shall have a quality assurance mechanism to ensure\nthe timeliness and quality of the review, the qualifications and independence of the\nphysician reviewer, and the confidentiality of medical records and review material.\n(8) Neither the independent review entity nor any reviewers of the entity, shall have any\nmaterial, professional, familial, or financial conflict of interest with any of the\nfollowing:\n(a) The insurer involved in the review;\n(b) Any officer, director, or management employee of the insurer;\n(c) The provider proposing the service or treatment or any associated independent\npractice association;\n(d) The institution at which the service or treatment would be provided;\n(e) The development or manufacture of the principal drug, device, procedure, or\nother therapy proposed for the covered person whos e treatment is under\nreview; or\n(f) The covered person.\n(9) As used in this section, \"conflict of interest\" shall not be interpreted to include:\n(a) A contract under which an academic medical center or other similar medical\ncenter provides health care serv ices to covered persons, except for academic\nmedical centers that may provide the service under review;\n(b) Provider affiliations which are limited to staff privileges; or\n(c) A specialist reviewer's relationship with an insurer as a contracting health care\nprovider, except for a specialist reviewer proposing to provide the service\nunder review.\n(10) On an annual basis, the independent review entity shall report to the department the\nfollowing information:\n(a) The number of independent review decisions in favor of covered persons;\n(b) The number of independent review decisions in favor of insurers;\n(c) The average turnaround time for an independent review decision;\n(d) The number of cases in which the independent review entity did not reach a\ndecision in the time specified in statute or administrative regulation; and\n(e) The reasons for any delay.","path":[],"source_url":"https://apps.legislature.ky.gov/law/statutes/statute.aspx?id=29314","current_through":"Includes enactments through the 2026 Regular Session","vintage":"09/05/2026","retrieved_at":"2026-09-05T20:57:47Z","sha256":"cfd026c32d51e9ee1d7b352da418c8fcc525d8cf9b4a3effed21ab7e7c610229","source_id":"us-ky","stale":false,"prev":"us-ky/krs-304.17a-625","next":"us-ky/krs-304.17a-629"},"notice":"GroundRules: Original legal text. Not legal advice."}