Section 304.17A-609 - Emergency administrative regulations governing utilization review and internal appeal to be promulgated by the departmentThe department shall promulgate emergency administrative regulations regarding utilization review and internal appeal, including the specification of information required of insurers and private review agents which shall, at a minimum, include:
(1) A utilization review plan that contains all information utilized for conducting preadmission, admission, readmission review, preauthorization, continued stay authorization, and retrospective review and which, for each type of review, includes: (a) Utilization review policies and procedures to evaluate proposed or delivered medical services;(b) Time frames for review;(c) A written summary describing the review process and required forms;(d) Documentation that actively practicing providers with appropriate qualifications are involved in the development or adoption of utilization review criteria relating to specialty and subspecialty areas;(e) Descriptions and names of review criteria upon which utilization review decisions are based; and(f) Additional standards, if any, for the consideration of special circumstances;(2) The type and qualifications of the personnel either employed or under contract to perform utilization review;(3) Assurance that a toll-free line will be provided that covered persons, authorized persons, and providers may use to contact the insurer or private review agent;(4) The policies and procedures to ensure that a representative of the insurer or private review agent shall be reasonably accessible to covered persons, authorized persons, and providers at least forty (40) hours per week during normal business hours;(5) The policies and procedures to ensure that all applicable state and federal laws to protect the confidentiality of individual medical records are followed;(6) A copy of the materials designed to inform covered persons, authorized persons, and providers of the toll-free number and the requirements of the utilization review plan;(7) A list of the entities for which the private review agent is performing utilization review in this state; and(8) Evidence of compliance or the ability to comply with the requirements and procedures established regarding utilization review and the administrative regulations promulgated thereunder.(9) In lieu of disclosing information specified in subsection (1) of this section, an insurer or private review agent may submit to the department evidence of accreditation or certification, if any, with a nationally recognized accreditation organization that oversees the information described in subsections (1) to (8) of this section, provided that the department may still require the information in subsection (8) of this section or other information to demonstrate compliance with the requirements of this section and KRS 304.17A-600, 304.17A-607, 304.17A-613, 304.17A-617, 304.17A-623, and 304.17A-625 not covered by the standards of the nationally recognized accreditation organization, as well as basic information necessary for the department to contact the insurer or private review agent. Nothing in this subsection shall be construed to prohibit or in any way limit the department's authority to require the submission of information specified in subsections (1) to (8) of this section or any other information the department deems necessary for purposes of investigating a complaint that the insurer or private review agent is not in compliance with KRS 304.17A-600 to 304.17A-633.Effective:7/15/2010
Amended 2010, Ky. Acts ch. 24, sec. 1237, effective7/15/2010. -- Amended 2002, Ky. Acts ch. 181, sec. 6, effective 7/15/2002. -- Created 2000, Ky. Acts ch. 262, sec. 5, effective 7/14/2000.