Kentucky Statutes 304.17A-605 – Requirements and procedures for utilization review — Exception for private review agent operating under contract with the federal government
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(1) KRS § 304.17A-600, 304.17A-603, 304.17A-605, 304.17A-607, 304.17A-609,
304.17A-611, 304.17A-613, and 304.17A-615 set forth the requirements and procedures regarding utilization review and shall apply to:
(a) Any insurer or its private review agent that provides or performs utilization review in connection with a health benefit plan or a limited health service benefit plan; and
(b) Any private review agent that performs utilization review functions on behalf of any person providing or administering health benefit plans or limited health service benefit plans.
(2) Where an insurer or its agent provides or performs utilization review, and in all instances where internal appeals as set forth in KRS § 304.17A-617 are involved, the insurer or its agent shall be responsible for:
(a) Monitoring all utilization reviews and internal appeals carried out by or on behalf of the insurer;
(b) Ensuring that all requirements of KRS § 304.17A-600 to KRS § 304.17A-633 are met; (c) Ensuring that all administrative regulations promulgated in accordance with
KRS § 304.17A-609, 304.17A-613, and 304.17A-629 are complied with; and
(d) Ensuring that appropriate personnel have operational responsibility for the performance of the insurer’s utilization review plan.
(3) A private review agent that operates solely under contract with the federal government for utilization review or patients eligible for hospital services under Title XVIII of the Social Security Act shall not be subject to the registration requirements set forth in KRS § 304.17A-607, 304.17A-609, and 304.17A-613.
Effective: July 15, 2002
History: Amended 2002 Ky. Acts ch. 105, sec. 1, effective July 15, 2002. — Created
2000 Ky. Acts ch. 262, sec. 3, effective July 14, 2000.
304.17A-611, 304.17A-613, and 304.17A-615 set forth the requirements and procedures regarding utilization review and shall apply to:
Terms Used In Kentucky Statutes 304.17A-605
- agent: includes managing general agent unless the context requires otherwise. See Kentucky Statutes 304.9-085
- Contract: A legal written agreement that becomes binding when signed.
- Federal: refers to the United States. See Kentucky Statutes 446.010
- Insurer: means any insurance company. See Kentucky Statutes 304.17A-005
(a) Any insurer or its private review agent that provides or performs utilization review in connection with a health benefit plan or a limited health service benefit plan; and
(b) Any private review agent that performs utilization review functions on behalf of any person providing or administering health benefit plans or limited health service benefit plans.
(2) Where an insurer or its agent provides or performs utilization review, and in all instances where internal appeals as set forth in KRS § 304.17A-617 are involved, the insurer or its agent shall be responsible for:
(a) Monitoring all utilization reviews and internal appeals carried out by or on behalf of the insurer;
(b) Ensuring that all requirements of KRS § 304.17A-600 to KRS § 304.17A-633 are met; (c) Ensuring that all administrative regulations promulgated in accordance with
KRS § 304.17A-609, 304.17A-613, and 304.17A-629 are complied with; and
(d) Ensuring that appropriate personnel have operational responsibility for the performance of the insurer’s utilization review plan.
(3) A private review agent that operates solely under contract with the federal government for utilization review or patients eligible for hospital services under Title XVIII of the Social Security Act shall not be subject to the registration requirements set forth in KRS § 304.17A-607, 304.17A-609, and 304.17A-613.
Effective: July 15, 2002
History: Amended 2002 Ky. Acts ch. 105, sec. 1, effective July 15, 2002. — Created
2000 Ky. Acts ch. 262, sec. 3, effective July 14, 2000.