{"data":{"id":"us-ky/krs-304.17b-011","jurisdiction":"us-ky","citation":"KRS 304.17B-011","heading":"Third-party administrator to administer Kentucky Access -- Selection","body":"and duties -- Reimbursement for expenses.\n(1) The Office of Health Data and Analytics shall select a third -party administrator,\nthrough the state competitive bidding p rocess, to administer Kentucky Access. The\nthird-party administrator shall be an administrator licensed by the department. The\noffice shall consider criteria in selecting a third -party administrator that shall\ninclude, but not be limited to, the following:\n(a) A third-party administrator's proven ability to demonstrate performance of the\noperations of an insurer to include the following: enrollee enrollment,\neligibility determination, provider enrollment and credentialing, utilization\nmanagement, quality im provement, drug utilization review, premium billing\nand collection, claims payment, and data reporting;\n(b) The total cost to administer Kentucky Access;\n(c) A third -party administrator's proven ability to demonstrate that Kentucky\nAccess shall be administered in a cost-efficient manner;\n(d) A third-party administrator's proven ability to demonstrate experience in two\n(2) or more states administering a risk pool for a minimum of a three (3) year\nperiod; and\n(e) A third-party administrator's financial condition and stability.\n(2) The office may contract with the third -party administrator for a period of four (4)\nyears with an option for a two (2) year extension as approved by the office on a\nyear-by-year contract basis. At least one (1) year prior to the expi ration of the third-\nparty administrator's contract, the office may solicit third -party administrators,\nincluding the current third -party administrator, to submit bids to serve as the third -\nparty administrator for the succeeding four (4) year period.\n(3) In addition to any duties and obligations set forth in the contract with the third-party\nadministrator, the third-party administrator shall:\n(a) Develop and establish policies and procedures for enrollee enrollment,\neligibility determination, provider enroll ment and credentialing, utilization\nmanagement, case management, disease management, quality improvement,\ndrug utilization review, premium billing and collection, data reporting, and\nother responsibilities determined by the office;\n(b) Develop and establish policies and procedures for paying the agent referral fee\nunder KRS 304.17B-001 to 304.17B-031;\n(c) Develop and establish policies and procedures to ensure timely and efficient\npayment of claims to include, but not limited to, the following:\n1. Develop a nd provide a claims billing manual to health care providers\nenrolled in Kentucky Access that includes information relating to the\nproper billing of a claim and the types of claim forms to use;\n2. Payment of all claims in accordance with the provisions of this chapter,\nKRS 304.12 -237, and the administrative regulations promulgated\nthereunder; and\n3. Notification to an enrollee through an explanation of benefits if a claim\nis denied or if there is en rollee financial responsibility of a paid claim\nfor deductible or coinsurance amounts;\n(d) Issue denial letters under KRS 304.17A-540 for denial of preauthorization and\nprecertification requests for medical necessity and medical appropriateness\ndeterminations;\n(e) Submit information to the office and the department under KRS 304.17A-330;\n(f) Submit reports to the office regarding the operation and financial condition of\nKentucky Access. The frequency, content, and form of the reports shall be\ndetermined by the office;\n(g) Submit an annual report to the office three (3) months after the end of each\ncalendar year. The annual report shall include:\n1. Earned premium;\n2. Administrative expenses;\n3. Incurred losses for the year;\n4. Paid losses for the year;\n5. Number of enrollees enrolled in Kentucky Access by category of\neligibility; and\n6. Any other information requested by the office; and\n(h) Be subject to examination by the office under Subtitles 2 and 3 of this chapter.\n(4) The third-party administrator shall be paid for necessary and reasonable expenses,\nas provided in the contract between the office and the third-party administrator.","path":[],"source_url":"https://apps.legislature.ky.gov/law/statutes/statute.aspx?id=50954","current_through":"Includes enactments through the 2026 Regular Session","vintage":"09/05/2026","retrieved_at":"2026-09-05T20:57:48Z","sha256":"181cb250109bb3bb36fe373d1469e301cbea63123ff7711d4467ed80c508ea99","source_id":"us-ky","stale":false,"prev":"us-ky/krs-304.17b-009","next":"us-ky/krs-304.17b-013"},"notice":"GroundRules: Original legal text. Not legal advice."}