Kentucky Statutes 304.17A-540 – Disclosure of limitations on coverage — Denial letter
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(1) Any insurer that limits coverage for any treatment, procedure, a drug, or device shall define the limitations and fully disclose those limits in the health insurance policy or certificate coverage.
(2) (a) Any insurer that denies coverage for a treatment, procedure, a drug that requires prior approval, or device for an enrollee shall provide the enrollee with a denial letter that shall include:
1. The name, license number, state of licensure, and title of the person making the decision;
2. A statement setting forth the specific medical and scientific reasons for denying coverage of a service, if the coverage is denied for reasons of medical necessity; and
3. Instructions for initiating or complying with the plan’s grievance or appeal procedure stating at a minimum whether the appeal must be in writing, any time limitations or schedules for filing appeals and the name and phone number of a contact person who can provide additional information.
(b) The denial letter shall be provided within:
1. Two (2) regular working days of the submitted request where preauthorization for a treatment, procedure, drug, or device is involved;
2. Twenty-four (24) hours of the submitted request where hospital preadmission review is sought;
3. Twenty (20) working days of the receipt of requested medical information where the plan has initiated a retrospective review; and
4. Twenty (20) working days of the initiation of the review process in all other instances.
Effective: July 14, 2000
History: Amended 2000 Ky. Acts ch. 500, sec. 6, effective July 14, 2000. — Created
1998 Ky. Acts ch. 496, sec. 33, effective April 10, 1998.
(2) (a) Any insurer that denies coverage for a treatment, procedure, a drug that requires prior approval, or device for an enrollee shall provide the enrollee with a denial letter that shall include:
Terms Used In Kentucky Statutes 304.17A-540
- Appeal: A request made after a trial, asking another court (usually the court of appeals) to decide whether the trial was conducted properly. To make such a request is "to appeal" or "to take an appeal." One who appeals is called the appellant.
- Insurer: means any insurance company. See Kentucky Statutes 304.17A-005
- State: when applied to a part of the United States, includes territories, outlying possessions, and the District of Columbia. See Kentucky Statutes 446.010
- Treatment: when used in a criminal justice context, means targeted interventions
that focus on criminal risk factors in order to reduce the likelihood of criminal behavior. See Kentucky Statutes 446.010
1. The name, license number, state of licensure, and title of the person making the decision;
2. A statement setting forth the specific medical and scientific reasons for denying coverage of a service, if the coverage is denied for reasons of medical necessity; and
3. Instructions for initiating or complying with the plan’s grievance or appeal procedure stating at a minimum whether the appeal must be in writing, any time limitations or schedules for filing appeals and the name and phone number of a contact person who can provide additional information.
(b) The denial letter shall be provided within:
1. Two (2) regular working days of the submitted request where preauthorization for a treatment, procedure, drug, or device is involved;
2. Twenty-four (24) hours of the submitted request where hospital preadmission review is sought;
3. Twenty (20) working days of the receipt of requested medical information where the plan has initiated a retrospective review; and
4. Twenty (20) working days of the initiation of the review process in all other instances.
Effective: July 14, 2000
History: Amended 2000 Ky. Acts ch. 500, sec. 6, effective July 14, 2000. — Created
1998 Ky. Acts ch. 496, sec. 33, effective April 10, 1998.