{"data":{"id":"us-ky/krs-304.17a-706","jurisdiction":"us-ky","citation":"KRS 304.17A-706","heading":"Contested claims -- Delay of payment -- Conditions -- Procedure.","body":"(1) An insurer may contest a clean claim only in the following instances:\n(a) The insurer has reasonable documented grounds to believe that the clean\nclaim involves a preexisting condition, coordination of benefits within the\nmeaning of KRS 304.18 -085, or that  another insurer is primarily responsible\nfor the claim;\n(b) The insurer will conduct a retrospective review of the services identified on\nthe claim;\n(c) The insurer has information that the claim was submitted fraudulently; or\n(d) The covered person's or group's premium has not been paid.\n(2) (a) If an insurer requires a provider to submit health claim attachments to the\nclaim before the claim will be paid, the insurer shall identify the specific\nrequired health claim attachments in its provider manual or other document\nthat sets forth the procedure for filing claims with the insurer. The insurer\nshall provide sixty (60) days' advance written notice of modifications to the\nprovider manual that materially change the type or content of the health claim\nattachments or other documents to be submitted.\n(b) If a provider submits a clean claim with the required health claim attachments\nas specified in the provider manual or other document that sets forth the\nprocedure for filing claims with the insurer, the insurer  shall pay or deny the\nclaim within the required claims payment time frame established in KRS\n304.17A-702.\n(c) If an insurer conducts a retrospective review of a claim and requires an\nattachment not specified in the provider manual or other document that s ets\nforth the procedure for filing claims, the insurer shall:\n1. Notify the provider, in writing or electronically within the claims\npayment time frame established in KRS 304.17A-702, of the service that\nwill be retrospectively reviewed and the specific in formation needed\nfrom the provider regarding the insurer's review of a claim;\n2. Complete the retrospective review within twenty (20) business days of\nthe insurer's receipt of the medical information described in this\nsubsection; and\n3. Subject to paragraph (d) of this subsection, add interest to the amount of\nthe claim, to be paid at a rate of twelve percent (12%) per annum, or at a\nrate in accordance with KRS 304.17A -730, accruing from the\nappropriate claim payment time frame established in KRS 304.17A -613\nafter the claim was received by the insurer through the date upon which\nthe claim is paid.\n(d) If the provider fails to submit the information requested under subparagraph\n(c) 1. of this subsection within fifteen (15) business days from the date of the\nreceipt of the notice, the insurer shall not be required to pay interest.\n(3) (a) If a claim or po rtion thereof is contested by an insurer on the basis that the\ninsurer has not received information reasonably necessary to determine insurer\nliability for the claim or portion thereof, or if the insurer contests the claim on\nthe reasonable and documented belief that the claim involves the coordination\nof benefits within the meaning of KRS 304.18 -085, or questions of pre -\nexisting conditions, the insurer shall, within the applicable claims payment\ntime frame established in KRS 304.17A -702, provide written or  electronic\nnotice to the provider, covered person, group policyholder, or other insurer, as\nappropriate, with an itemization of all new, never-before-provided information\nthat is needed.\n(b) The insurer shall pay or deny the claim within thirty (30) calen dar days of\nreceiving the additional information described in paragraph (a) of this\nsubsection. If the insurer does not receive the additional information described\nin paragraph (a) of this subsection within fifteen (15) business days from the\ndate of rece ipt of the notice set forth in paragraph (a) of this subsection, the\ninsurer may deny the claim. Any claim denied under this paragraph may be\nresubmitted by the provider and any resubmitted claim shall not be denied on\nthe basis of timeliness if the resubmitted claim is made with the timeframe for\nsubmitting claims established by the insurer beginning on the date of denial.","path":[],"source_url":"https://apps.legislature.ky.gov/law/statutes/statute.aspx?id=29332","current_through":"Includes enactments through the 2026 Regular Session","vintage":"09/05/2026","retrieved_at":"2026-09-05T20:57:48Z","sha256":"074f95436aade6d95773381e245e9c890f147ebc037526c56012b9127ba156db","source_id":"us-ky","stale":false,"prev":"us-ky/krs-304.17a-705","next":"us-ky/krs-304.17a-708"},"notice":"GroundRules: Original legal text. Not legal advice."}