Kentucky Statutes 304.17A-625 – Factors to be considered by independent review entity conducting external review — Basis for decision — Insurer’s responsibilities — Contents, admissibility, and effect of decision — Consequence of insurer’s fail…
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(1) In making its decision, an independent review entity conducting the external review shall take into account all of the following:
(a) Information submitted by the insurer, the covered person, the authorized person, and the covered person’s provider, including the following:
1. The covered person’s medical records;
2. The standards, criteria, and clinical rationale used by the insurer to make its decision; and
3. The insurer’s health benefit plan;
(b) Findings, studies, research, and other relevant documents of government agencies and nationally recognized organizations, including the National Institutes of Health, or any board recognized by the National Institutes of Health, the National Cancer Institute, the National Academy of Sciences, and the United States Food and Drug Administration, the Centers for Medicare & Medicaid Services of the United States Department of Health and Human Services, and the Agency for Health Care Research and Quality; and
(c) Relevant findings in peer-reviewed medical or scientific literature, published opinions of nationally recognized medical specialists, and clinical guidelines adopted by relevant national medical societies.
(2) The independent review entity shall base its decision on the information submitted under subsection (1) of this section. In making its decision, the independent review entity shall consider safety, appropriateness, and cost effectiveness.
(3) The insurer shall provide any coverage determined by the independent review entity to be medically necessary. The independent review entity shall not be permitted to allow coverage for services specifically limited or excluded by the insurer in its health benefit plan. The decision shall apply only to the individual covered person’s external review.
(4) Nothing in this section shall be construed as requiring an insurer to provide coverage for out of network services, procedures, or tests, except as set forth in KRS § 304.17A-515(1)(c) and 304.17A-550.
(5) The insurer shall be responsible for the cost of the external review.
(6) The independent review entity shall provide to the covered person, treating provider, insurer, and the department a decision which shall include:
(a) The findings for either the insurer or covered person regarding each issue under review;
(b) The proposed service, treatment, drug, device, or supply for which the review was performed;
(c) The relevant provisions in the insurer’s health benefit plan and how applied;
and
(d) The relevant provisions of any nationally recognized and peer-reviewed medical or scientific documents used in the external review.
(7) The decision of the independent review entity shall not be made solely for the convenience of the insurer, the covered person, or the provider.
(8) Consistent with the rules of evidence, a written decision prepared by an independent review entity shall be admissible in any civil action related to the adverse determination. The independent review entity’s decision shall be presumed to be a scientifically valid and accurate description of the state of medical knowledge at the time it was written.
(9) The decision of the independent review entity shall be binding on the insurer with respect to that covered person. Failure of the insurer to provide coverage as required by the independent review entity shall:
(a) Be a violation of the insurance code of a nature sufficient to warrant the commissioner revoking or suspending the insurer’s license or certificate of authority; and
(b) Constitute an unfair claims settlement practice as set forth in KRS § 304.12-
230.
(10) Failure to provide coverage as required by the independent review entity shall also subject the insurer to the provisions of KRS § 304.99-010 and KRS § 304.99-020 and require the insurer to pay the claim that was the subject of the external review, without need for the covered person or authorized person to further establish a right as to the payment amount. Reasonable attorney fees associated with the actions of the insured necessary to collect amounts owed the covered person shall be assessed against and borne by the insurer.
(11) The insurer shall implement the decision of the independent review entity whether the covered person has disenrolled or remains enrolled with the insurer.
(12) If the covered person has been disenrolled with the insurer, the insurer shall only be required to provide the treatment, service, drug, or device that was previously denied by the insurer, its agent, or designee and later approved by the independent review entity for a period not to exceed thirty (30) days.
(13) Within thirty (30) days of the decision in favor of the covered person by the independent review entity, the insurer shall provide written notification to the department that the decision has been implemented in accordance with this section.
(14) An independent review entity and any medical specialist the entity utilizes in conducting an external review shall not be liable in damages in a civil action for injury, death, or loss to person or property and is not subject to professional disciplinary action for making, in good faith, any finding, conclusion, or determination required to complete the external review. This subsection does not grant immunity from civil liability or professional disciplinary action to an independent review entity or medical specialist for an action that is outside the scope of authority granted in KRS § 304.17A-621, 304.17A-623, and 304.17A-625.
(15) Nothing in KRS § 304.17A-600 to KRS § 304.17A-633 shall be construed to create a cause of action against any of the following:
(a) An employer that provides health care benefits to employees through a health benefit plan;
(b) A medical expert, private review agent, or independent review entity that participates in the utilization review, internal appeal, or external review addressed in KRS § 304.17A-600 to KRS § 304.17A-633; or
(c) An insurer or provider acting in good faith and in accordance with any finding, conclusion, or determination of an Independent Review Entity acting within the scope of authority set forth in KRS § 304.17A-621, 304.17A-623, and 304.17A-625.
(16) The covered person, insurer, or provider in the external review may submit written complaints to the department regarding any independent review entity’s actions believed to be an inappropriate application of the requirements set forth in KRS
304.17A-621, 304.17A-623, and 304.17A-625. The department shall promptly review the complaint, and if the department determines that the actions of the independent review entity were inappropriate, the department shall take corrective measures, including decertification or suspension of the independent review entity from further participation in external reviews. The department’s actions shall be subject to the powers and administrative procedures set forth in Subtitle 17A of KRS Chapter 304.
Effective: July 15, 2010
History: Amended 2010 Ky. Acts ch. 24, sec. 1242, effective July 15, 2010. — Amended 2002 Ky. Acts ch. 181, sec. 10, effective July 15, 2002. — Created 2000
Ky. Acts ch. 262, sec. 13, effective July 14, 2000.
(a) Information submitted by the insurer, the covered person, the authorized person, and the covered person’s provider, including the following:
Terms Used In Kentucky Statutes 304.17A-625
- Action: includes all proceedings in any court of this state. See Kentucky Statutes 446.010
- 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.
- Attorney: means attorney-at-law. See Kentucky Statutes 446.010
- Complaint: A written statement by the plaintiff stating the wrongs allegedly committed by the defendant.
- Damages: Money paid by defendants to successful plaintiffs in civil cases to compensate the plaintiffs for their injuries.
- Evidence: Information presented in testimony or in documents that is used to persuade the fact finder (judge or jury) to decide the case for one side or the other.
- Insurer: means any insurance company. See Kentucky Statutes 304.17A-005
- provider: means any:
(a) Advanced practice registered nurse licensed under KRS Chapter 314. See Kentucky Statutes 304.17A-005 - Settlement: Parties to a lawsuit resolve their difference without having a trial. Settlements often involve the payment of compensation by one party in satisfaction of the other party's claims.
- 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 covered person’s medical records;
2. The standards, criteria, and clinical rationale used by the insurer to make its decision; and
3. The insurer’s health benefit plan;
(b) Findings, studies, research, and other relevant documents of government agencies and nationally recognized organizations, including the National Institutes of Health, or any board recognized by the National Institutes of Health, the National Cancer Institute, the National Academy of Sciences, and the United States Food and Drug Administration, the Centers for Medicare & Medicaid Services of the United States Department of Health and Human Services, and the Agency for Health Care Research and Quality; and
(c) Relevant findings in peer-reviewed medical or scientific literature, published opinions of nationally recognized medical specialists, and clinical guidelines adopted by relevant national medical societies.
(2) The independent review entity shall base its decision on the information submitted under subsection (1) of this section. In making its decision, the independent review entity shall consider safety, appropriateness, and cost effectiveness.
(3) The insurer shall provide any coverage determined by the independent review entity to be medically necessary. The independent review entity shall not be permitted to allow coverage for services specifically limited or excluded by the insurer in its health benefit plan. The decision shall apply only to the individual covered person’s external review.
(4) Nothing in this section shall be construed as requiring an insurer to provide coverage for out of network services, procedures, or tests, except as set forth in KRS § 304.17A-515(1)(c) and 304.17A-550.
(5) The insurer shall be responsible for the cost of the external review.
(6) The independent review entity shall provide to the covered person, treating provider, insurer, and the department a decision which shall include:
(a) The findings for either the insurer or covered person regarding each issue under review;
(b) The proposed service, treatment, drug, device, or supply for which the review was performed;
(c) The relevant provisions in the insurer’s health benefit plan and how applied;
and
(d) The relevant provisions of any nationally recognized and peer-reviewed medical or scientific documents used in the external review.
(7) The decision of the independent review entity shall not be made solely for the convenience of the insurer, the covered person, or the provider.
(8) Consistent with the rules of evidence, a written decision prepared by an independent review entity shall be admissible in any civil action related to the adverse determination. The independent review entity’s decision shall be presumed to be a scientifically valid and accurate description of the state of medical knowledge at the time it was written.
(9) The decision of the independent review entity shall be binding on the insurer with respect to that covered person. Failure of the insurer to provide coverage as required by the independent review entity shall:
(a) Be a violation of the insurance code of a nature sufficient to warrant the commissioner revoking or suspending the insurer’s license or certificate of authority; and
(b) Constitute an unfair claims settlement practice as set forth in KRS § 304.12-
230.
(10) Failure to provide coverage as required by the independent review entity shall also subject the insurer to the provisions of KRS § 304.99-010 and KRS § 304.99-020 and require the insurer to pay the claim that was the subject of the external review, without need for the covered person or authorized person to further establish a right as to the payment amount. Reasonable attorney fees associated with the actions of the insured necessary to collect amounts owed the covered person shall be assessed against and borne by the insurer.
(11) The insurer shall implement the decision of the independent review entity whether the covered person has disenrolled or remains enrolled with the insurer.
(12) If the covered person has been disenrolled with the insurer, the insurer shall only be required to provide the treatment, service, drug, or device that was previously denied by the insurer, its agent, or designee and later approved by the independent review entity for a period not to exceed thirty (30) days.
(13) Within thirty (30) days of the decision in favor of the covered person by the independent review entity, the insurer shall provide written notification to the department that the decision has been implemented in accordance with this section.
(14) An independent review entity and any medical specialist the entity utilizes in conducting an external review shall not be liable in damages in a civil action for injury, death, or loss to person or property and is not subject to professional disciplinary action for making, in good faith, any finding, conclusion, or determination required to complete the external review. This subsection does not grant immunity from civil liability or professional disciplinary action to an independent review entity or medical specialist for an action that is outside the scope of authority granted in KRS § 304.17A-621, 304.17A-623, and 304.17A-625.
(15) Nothing in KRS § 304.17A-600 to KRS § 304.17A-633 shall be construed to create a cause of action against any of the following:
(a) An employer that provides health care benefits to employees through a health benefit plan;
(b) A medical expert, private review agent, or independent review entity that participates in the utilization review, internal appeal, or external review addressed in KRS § 304.17A-600 to KRS § 304.17A-633; or
(c) An insurer or provider acting in good faith and in accordance with any finding, conclusion, or determination of an Independent Review Entity acting within the scope of authority set forth in KRS § 304.17A-621, 304.17A-623, and 304.17A-625.
(16) The covered person, insurer, or provider in the external review may submit written complaints to the department regarding any independent review entity’s actions believed to be an inappropriate application of the requirements set forth in KRS
304.17A-621, 304.17A-623, and 304.17A-625. The department shall promptly review the complaint, and if the department determines that the actions of the independent review entity were inappropriate, the department shall take corrective measures, including decertification or suspension of the independent review entity from further participation in external reviews. The department’s actions shall be subject to the powers and administrative procedures set forth in Subtitle 17A of KRS Chapter 304.
Effective: July 15, 2010
History: Amended 2010 Ky. Acts ch. 24, sec. 1242, effective July 15, 2010. — Amended 2002 Ky. Acts ch. 181, sec. 10, effective July 15, 2002. — Created 2000
Ky. Acts ch. 262, sec. 13, effective July 14, 2000.