Kentucky Statutes 304.38-225 – Requirements for health maintenance organization that provides hospital benefits coverage and requires utilization review of benefits
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(1) Every health maintenance organization in this state which provides coverage of hospital benefits and requires the utilization review of such benefits or administers a health benefit program which provides for the coverage of hospital benefits and requires the utilization review of such benefits by a private review agent shall:
(a) Be a registered private review agent in accordance with KRS § 304.17A-607 and administrative regulations promulgated under the authority of KRS
304.17A-613; or
(b) Contract with a private review agent that has been registered in accordance with KRS § 304.17A-607 and administrative regulations promulgated under the authority of KRS § 304.17A-613.
(2) Notwithstanding any other provision of KRS § 304.17A-603, 304.17A-605, 304.17A-
607, 304.17A-609, 304.17A-611, 304.17A-613, and 304.17A-615, a health maintenance organization shall not deny or reduce payment of health benefits to any person, licensed practitioner, or health facility for covered services which have been rendered to an insured unless:
(a) Notice of denial has been issued. The notice shall inform patients, authorized persons, and health-care providers of their right to appeal adverse determinations of a utilization review by the insurer, its designee, or private review agent to the insurer for the internal review process established by the insurer in accordance with KRS § 304.17A-617 and KRS § 304.17A-619. The notice shall also include instructions on filing an internal appeal; and
(b) The health maintenance organization is in compliance with subsection (1) of this section.
Effective: July 14, 2000
History: Amended 2000 Ky. Acts ch. 262, sec. 31, effective July 14, 2000. — Amended
1998 Ky. Acts ch. 426, sec. 528, effective July 15, 1998. — Amended 1996 Ky. Acts ch. 353, sec. 4, effective July 15, 1996. — Created 1990 Ky. Acts ch. 451, sec. 11, effective July 13, 1990.
(a) Be a registered private review agent in accordance with KRS § 304.17A-607 and administrative regulations promulgated under the authority of KRS
Terms Used In Kentucky Statutes 304.38-225
- agent: includes managing general agent unless the context requires otherwise. See Kentucky Statutes 304.9-085
- 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.
- Contract: A legal written agreement that becomes binding when signed.
- Health maintenance organization: means any person who undertakes to provide, directly or through arrangements with others, health care services to individuals enrolled with such an organization on a per capita or a predetermined, fixed prepayment basis. See Kentucky Statutes 304.38-030
- Person: includes but is not limited to any individual, partnership, association, trust, or corporation. See Kentucky Statutes 304.38-030
- State: when applied to a part of the United States, includes territories, outlying possessions, and the District of Columbia. See Kentucky Statutes 446.010
304.17A-613; or
(b) Contract with a private review agent that has been registered in accordance with KRS § 304.17A-607 and administrative regulations promulgated under the authority of KRS § 304.17A-613.
(2) Notwithstanding any other provision of KRS § 304.17A-603, 304.17A-605, 304.17A-
607, 304.17A-609, 304.17A-611, 304.17A-613, and 304.17A-615, a health maintenance organization shall not deny or reduce payment of health benefits to any person, licensed practitioner, or health facility for covered services which have been rendered to an insured unless:
(a) Notice of denial has been issued. The notice shall inform patients, authorized persons, and health-care providers of their right to appeal adverse determinations of a utilization review by the insurer, its designee, or private review agent to the insurer for the internal review process established by the insurer in accordance with KRS § 304.17A-617 and KRS § 304.17A-619. The notice shall also include instructions on filing an internal appeal; and
(b) The health maintenance organization is in compliance with subsection (1) of this section.
Effective: July 14, 2000
History: Amended 2000 Ky. Acts ch. 262, sec. 31, effective July 14, 2000. — Amended
1998 Ky. Acts ch. 426, sec. 528, effective July 15, 1998. — Amended 1996 Ky. Acts ch. 353, sec. 4, effective July 15, 1996. — Created 1990 Ky. Acts ch. 451, sec. 11, effective July 13, 1990.