{"data":{"id":"us-ky/krs-304.38-225","jurisdiction":"us-ky","citation":"KRS 304.38-225","heading":"Requirements for health maintenance organization that provides","body":"hospital benefits coverage and requires utilization review of benefits.\n(1) Every health maintenance organization in this state which provides coverage of\nhospital benefits and requires the utilization review of such benefits or administers a\nhealth benefit program which provides for the coverage of hospital benefits and\nrequires the utilization review of such benefits by a private review agent shall:\n(a) Be a registered private review a gent in accordance with KRS 304.17A -607\nand administrative regulations promulgated under the authority of KRS\n304.17A-613; or\n(b) Contract with a private review agent that has been registered in accordance\nwith KRS 304.17A-607 and administrative regulations promulgated under the\nauthority of KRS 304.17A-613.\n(2) Notwithstanding any other provision of KRS 304.17A-603, 304.17A-605, 304.17A-\n607, 304.17A -609, 304.17A -611, 304.17A -613, and 304.17A -615, a health\nmaintenance organization shall not deny or reduce payment of health benefits to any\nperson, licensed practitioner, or health facility for covered services which have been\nrendered to an insured unless:\n(a) Notice of denial has been issued. The notice shall inform patients, authorized\npersons, and health -care providers of their right to appeal adverse\ndeterminations of a utilization review by the insurer, its designee, or private\nreview agent to the insurer for the internal review process established by the\ninsurer in accordance with KRS 304.17A -617 and 304. 17A-619. The notice\nshall also include instructions on filing an internal appeal; and\n(b) The health maintenance organization is in compliance with subsection (1) of\nthis section.","path":[],"source_url":"https://apps.legislature.ky.gov/law/statutes/statute.aspx?id=30008","current_through":"Includes enactments through the 2026 Regular Session","vintage":"09/05/2026","retrieved_at":"2026-09-05T20:57:57Z","sha256":"8037f58eaa20dc53bbdb46b678a2e453eaccf8a2f50a2ee1477a990cca8fbcb6","source_id":"us-ky","stale":false,"prev":"us-ky/krs-304.38-220","next":"us-ky/krs-304.38-230"},"notice":"GroundRules: Original legal text. Not legal advice."}