Kentucky Statutes 304.32-147 – Requirements for health service corporation that issues policy or administers program providing for utilization review of benefits
Current as of: 2024 | Check for updates
|
Other versions
(1) Every nonprofit hospital, medical-surgical, dental, and health service corporation proposing to issue or deliver in this state a health insurance policy or contract or administer a health benefit program which provides for the coverage of hospital benefits and the utilization review of those 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 nonprofit hospital, medical-surgical, dental, and health service corporation 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 appeal 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 appeal to the cabinet; and
(b) The nonprofit hospital, medical-surgical, dental, and health service corporation is in compliance with subsection (1) of this section.
Effective: July 14, 2000
History: Amended 2000 Ky. Acts ch. 262, sec. 29, effective July 14, 2000. — Amended
1998 Ky. Acts ch. 426, sec. 527, effective July 15, 1998. — Amended 1996 Ky. Acts ch. 353, sec. 3, effective July 15, 1996. — Created 1990 Ky. Acts ch. 451, sec. 9, 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 304.32-147
- 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.
- Corporation: A legal entity owned by the holders of shares of stock that have been issued, and that can own, receive, and transfer property, and carry on business in its own name.
- Corporation: may extend and be applied to any corporation, company, partnership, joint stock company, or association. See Kentucky Statutes 446.010
- 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 nonprofit hospital, medical-surgical, dental, and health service corporation 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 appeal 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 appeal to the cabinet; and
(b) The nonprofit hospital, medical-surgical, dental, and health service corporation is in compliance with subsection (1) of this section.
Effective: July 14, 2000
History: Amended 2000 Ky. Acts ch. 262, sec. 29, effective July 14, 2000. — Amended
1998 Ky. Acts ch. 426, sec. 527, effective July 15, 1998. — Amended 1996 Ky. Acts ch. 353, sec. 3, effective July 15, 1996. — Created 1990 Ky. Acts ch. 451, sec. 9, effective July 13, 1990.