KY. Rev. Statutes-Chapter 304-Subtitle 17A-Health Benefit Plans

See the bold text below:

Section 304.17A-600.  Definitions for section -- Prior authorization exemption program -- Program requirements and options. (Effective January 1, 2028)

Definitions for KRS 304.17A-600 to 304.17A-633.             

As used in KRS 304.17A-600 to 304.17A-633: 

(1) "Adverse benefit determination": 

(a) Has the same meaning as in 29 C.F.R. sec. 2560.503-1, as amended; and 

(b) Includes: 

1. A determination by an insurer or its designee that the health care services furnished or proposed to be furnished to a covered person are: 

a. Not medically necessary, as determined by the insurer or its designee; or 

b. Experimental or investigational, as determined by the insurer or its designee; and 

c. A coverage denial; 

(2) "Authorized person" means a parent, guardian, or other person authorized to act on behalf of a covered person with respect to health care decisions; 

(3) "Concurrent review" means utilization review conducted during a covered person's course of treatment or hospital stay; 

(4) "Coverage denial" means a determination that a service, procedure, treatment, drug, supply, or device is specifically limited or excluded under a covered person's health benefit plan; 

(5) "Covered person" means a person covered under a health benefit plan; (

6) "External review" means a review that is conducted by an independent review entity which meets specified criteria as established in KRS 304.17A-621, 304.17A623, 304.17A-625, and 304.17A-627; 

(7) "Health benefit plan" has the same meaning as in KRS 304.17A-005, except that for purposes of KRS 304.17A-600 to 304.17A-633, the term includes short-term coverage policies; 

(8) "Independent review entity" means an individual or organization certified by the department to perform external reviews under KRS 304.17A-621, 304.17A-623, 304.17A-625, and 304.17A-627; 

(9) "Insurer" means any of the following entities that issue or provide health benefit plans: 

(a) An insurance company; 

(b) Health maintenance organization; 

(c) Self-insurer or multiple employer welfare arrangement not exempt from state regulation by ERISA; 

(d) Provider-sponsored integrated health delivery network; 

(e) Self-insured employer-organized association; 

(f) Nonprofit hospital, medical-surgical, or health service corporation; or 

(g) Any other entity authorized to transact health insurance business in Kentucky; 

(10) "Internal appeals process" means a formal appeals process, as set forth in KRS 304.17A-617, established and maintained by the insurer, its designee, or private review agent; 

(11) "Nationally recognized accreditation organization": 

(a) Means a private nonprofit entity that: 

1. Sets national utilization review and internal appeal standards; and  

2. Conducts review of insurers, agents, or independent review entities for the purpose of accreditation or certification; and 

(b) Shall include the Accreditation Association for Ambulatory Health Care (AAAHC), the National Committee for Quality Assurance (NCQA), the American Accreditation Health Care Commission (URAC), the Joint Commission, or any other organization identified by the department; 

(12) "Private review agent" or "agent": 

(a) Means a person or entity performing utilization review that is either affiliated with, under contract with, or acting on behalf of any insurer or other person providing or administering health benefits to citizens of this Commonwealth; and 

(b) Does not include an independent review entity that performs external reviews; 

(13) "Prospective review": 

(a) Means a utilization review that is conducted prior to the provision of health care services; and 

(b) Includes any insurer's or agent's requirement that a covered person or provider notify the insurer or agent prior to providing a health care service, including but not limited to prior authorization, step therapy protocol, preadmission review, pretreatment review, utilization, and case management; 

(14) "Qualified personnel" means licensed physician, registered nurse, licensed practical nurse, medical records technician, or other licensed medical personnel who through training and experience shall render consistent decisions based on the review criteria; 

(15) "Registration" means an authorization issued by the department to an insurer or a private review agent to conduct utilization review; 

(16) "Retrospective review": 

(a) Means utilization review that is conducted after health care services have been provided to a covered person; and 

(b) Does not include the review of a claim that is limited to an evaluation of reimbursement levels, or adjudication of payment; 

(17) "Urgent health care services": 

(a) Means health care or treatment with respect to which the application of the time periods for making a nonurgent determination: 

1. Could seriously jeopardize the life or health of the covered person or the ability of the covered person to regain maximum function; or 

2. In the opinion of a physician with knowledge of the covered person's medical condition, would subject the covered person to severe pain that cannot be adequately managed without the care or treatment that is the subject of the utilization review; and 

(b) Includes all requests for hospitalization and outpatient surgery; 

(18) "Utilization review" means a review of the medical necessity and appropriateness of hospital resources and medical services given or proposed to be given to a covered person for purposes of determining the availability of payment. Areas of review include concurrent, prospective, and retrospective review; and 

(19) "Utilization review plan" means a description of the procedures governing utilization review activities performed by an insurer or a private review agent. 

See https://apps.legislature.ky.gov/law/statutes/chapter.aspx?id=38715

Section 304.17A-603. Application of KRS 304.17A-600 to 304.17A-633 -- Written procedures for coverage and utilization review determinations to be accessible on insurers' Web sites -- Preauthorization review requirements for insurers.

(1) KRS 304.17A-600 to 304.17A-633 shall apply to any insurer that covers citizens of the Commonwealth under a health benefit plan. 

(2) An insurer shall maintain written procedures for: 

(a) Determining whether a requested service, treatment, drug, or device is covered under the terms of a covered person's health benefit plan; 

(b) Making utilization review determinations; and 

(c) Notifying covered persons, authorized persons, and providers acting on behalf of covered persons of its determinations. 

(3) An insurer shall make the written procedures required by this section readily accessible on its Web site to covered persons, authorized persons, and providers. 

(4)(a) If an insurer requires preauthorization to be obtained for a service to be covered, the insurer shall maintain information on its publicly accessible Web site about the list of services and codes for which preauthorization is required. The Web site shall indicate, for each service required to be preauthorized: 

1. When preauthorization was required, including the effective date or dates and the termination date or dates, if applicable; 

2. The date the requirement was listed on the insurer's Web site; and 

3. Where applicable, the date that preauthorization was removed. 

(b) An insurer shall maintain a complete list of services for which preauthorization is required, including for all services where preauthorization is performed by an entity under contract with the insurer. 

Retroactive Denial

(c) An insurer shall not deny a claim for failure to obtain preauthorization if the preauthorization requirement was not in effect on the date of service on the claim. 

(5) Except as otherwise provided in this subtitle, prior authorization shall not be required for births or the inception of neonatal intensive care services and notification shall not be required as a condition of payment. 

(6) Unless otherwise specified by the provider's contract, an insurer shall not deem as incidental or deny supplies that are routinely used as part of a procedure when: 

(a) An associated procedure has been preauthorized; or 

(b) Preauthorization for the procedure is not required. 

See https://apps.legislature.ky.gov/law/statutes/chapter.aspx?id=38715

304.17A-605. Requirements and procedures for utilization review -- Exception for private review agent operating under contract with the federal government.  (Effective until January 1, 2028). 

(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 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. 

See https://apps.legislature.ky.gov/law/statutes/chapter.aspx?id=38715

Section 304.17A-605. Requirements and procedures for utilization review -- Exception for private review agent operating under contract with the federal government.  (Effective January 1, 2028).

 (1) (a) Except as provided in paragraph (b) of this subsection, 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: 

1. 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 

2. 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. 

(b) KRS 304.17A-606 sets forth additional requirements for prior authorization and shall apply to: 

1. Any insurer or its private review agent that provides or performs utilization review in connection with a health benefit plan; and 

2. Any private review agent that performs utilization review functions on behalf of any person providing and administering health 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 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. 

See https://apps.legislature.ky.gov/law/statutes/

Section 304.17A-606.  Definitions for section -- Prior authorization exemption program -- Program requirements and options.  (Effective January 1, 2028)

(1) As used in this section: 

(a) "Covered health care service" means a health care service furnished or proposed to be furnished to a covered person that is specifically available or included as a covered benefit in the covered person's health benefit plan; 

(b) "Electronic health record" has the same meaning as in 42 U.S.C. sec. 17921, as amended; 

(c) "Evaluation period" means a twelve (12) month period of time for which a health care provider's prior authorization experience is evaluated by an insurer or private review agent; 

(d) "Health care provider" has the same meaning as in KRS 304.17A-005, except for purposes of this section the term includes, if practicing independently, any: 

(1) Licensed clinical alcohol and drug counselor licensed under KRS Chapter 309; 

(2) Licensed psychologist, licensed psychological practitioner, or certified psychologist with autonomous functioning licensed or certified under the provisions of KRS Chapter 319; 

(3) Licensed professional clinical counselor licensed under KRS Chapter 335; 

(4) Licensed marriage and family therapist licensed under KRS Chapter 335; Licensed professional art therapist licensed under KRS Chapter 309; and 

(5) Licensed clinical social worker licensed under KRS Chapter 335.

(e) "Health care provider group" means two (2) or more health care providers that provide health care services within an entity that shares a common: 

1. Group provider number; or 

2. Tax identification number.

(f) "Health care service" has the same meaning as in KRS 304.17A-005, except for purposes of this section the term: 

1. Includes procedures, treatments, and services rendered by a health care provider as defined in this section; and 

2. Does not include the provision of prescription drugs; 

(g) "Interoperability standards" means the technical standards set forth in 45 C.F.R. sec. 170.215, as amended; 

(h) "Participating provider": 

1. Means a health care provider that has entered into a participating provider contract; and 

2. Includes a health care provider group if the insurer has elected to offer an exemption to the health care provider group under subsection (4)(b)2. of this section. 

(i) "Participating provider contract" means a contract between a health care provider, either directly or through a health care provider group, and an insurer for the provision of health care services under a health benefit plan; 

(j) "Utilization" means the number of claims submitted for a particular health care service under a health benefit plan by a participating provider; and 

(k) "Value-based care agreement" means a contractual agreement between a health care provider, either directly or through a health care provider group, and an insurer that: 

1. Incentivizes or rewards the provider based on one (1) or more of the following: 

a. Quality of care; 

b. Safety; 

c. Patient outcomes; 

d. Efficiency; 

e. Cost reduction; or 

f. Other factors; and 

2. May, but is not required to, include shared financial risk and rewards based on performance metrics. 

(2) An insurer or its private review agent shall not require a covered person, authorized person, or participating provider to obtain a prior authorization for a particular health care service under a health benefit plan if, at the time the health care service was provided, the provider had a prior authorization exemption for that particular health care service under a program offered under subsection (3) of this section. 

(3) Every insurer shall offer a program under which a participating provider may qualify for an exemption from the requirement to obtain prior authorization for any covered health care service that requires prior authorization. 

(4) The program offered under subsection (3) of this section: 

(a) Shall: 

1. Provide that a participating provider, for an evaluation period established by the insurer or private review agent, receive a prior authorization exemption for a particular health care service if, during the previous evaluation period, the provider met program terms and conditions established by the insurer or private review agent that are not in violation of this section; 

2. Not condition a prior authorization exemption upon the provider exceeding a ninety-three percent (93%) approval rate for prior authorization requests submitted by the provider for that health care service during an evaluation period; 

3. Require the insurer or its private review agent to evaluate, on an annual basis, whether a participating provider qualifies to receive a prior authorization exemption for each covered health care service for which the insurer requires prior authorization; 

4. Require each annual evaluation required under subparagraph 3. of this paragraph to be conducted on: 

a. For participating provider contracts that have a performance period of one (1) year, the contract's renewal date; or 

b. For participating provider contracts that have a performance period of greater than one (1) year, the annual anniversary date of the contract renewal; 

5. Require an insurer or its private review agent to notify each participating provider that qualifies for a prior authorization exemption within thirty (30) days after conducting the annual evaluation required under subparagraph 3. of this paragraph; 

6. Require an insurer or its private review agent to make available to a health care provider during the contracting process the requirements that the provider must meet to participate in the program; and 

7. Comply with any administrative regulation promulgated under KRS 304.2-110 for or as an aid to the effectuation of this section; and 

(b) May:

1. Offer a prior authorization exemption for any prescription drug; 

2. Offer a prior authorization exemption to a health care provider group in lieu of each participating provider practicing within a health care provider group; 

3. Condition a participating provider's eligibility to participate in the program on the provider satisfying one (1) or more of the following: 

a. The provider has entered into, either directly or through a health care provider group, a value-based care agreement with the insurer; 

b. The provider has been a participating provider for a minimum period of time established by the insurer or private review agent, except an established minimum period of time shall not be more than one (1) year; or 

(c) The provider: 

i. Complies with interoperability standards; and 

ii. Has entered into, either directly or through a health care provider group, an electronic health record access agreement with the insurer or private review agent; 

4. Provide that a participating provider shall not qualify for a prior authorization exemption for any particular health care service unless the provider's utilization for that health care service during the previous evaluation period meets any utilization requirement established by the insurer or private review agent, except an established utilization requirement shall not: 

a. Require a minimum utilization of more than twenty-four (24); or 

b. Impose a maximum utilization of less than one hundred ten percent (110%) of the participating provider's utilization for that particular health care service during the previous evaluation period; and 

5. Provide that an insurer or its private review agent may revoke a participating provider's prior authorization exemption for any particular health care service, or suspend or revoke a participating provider's participation in the program, if: 

a. The insurer or private review agent has evidence that the provider has engaged in fraud or abuse; or

b. The provider's utilization meets or exceeds a maximum utilization imposed under subparagraph 4.b. of this paragraph. 

(5) If an insurer or its private review agent determines that a participating provider is eligible to participate in the program offered under subsection (3) of this section, the insurer or private review agent shall send a notice to the provider that includes: 

(a) A statement that the provider is eligible to participate in the program; and 

(b) A list of each health care service that is subject to the elimination of prior authorization requirements under the program. 

(6) For all forms and notices sent to a participating provider in accordance with this section, or any administrative regulations promulgated under KRS 304.2-110 for or as an aid to the effectuation of this section, the insurer or its private review agent shall: 

(a) Provide a process for the provider to designate and update the provider's preferred manner for receiving the forms and notices; and 

(b) Send the forms and notices to the provider in the manner designated under paragraph (a) of this subsection. 

(7) This section shall not be construed to: 

(a) Prevent an insurer or its private review agent from requesting a health care provider to provide additional information about a health care service rendered to a covered person; or 

(b) Require coverage of a noncovered health care service under a covered person's health benefit plan. 

See https://apps.legislature.ky.gov/law/statutes/chapter.aspx?id=38715.

Section 304.17A-6061.  Commissioner to report to the Legislative Research Commission on prior authorization exemption program -- Contents of report.  (Effective January 1, 2028). 

The commissioner shall: 

(1)(a) Submit a written report not later than September 30 of each year to the Legislative Research Commission for referral to the Interim Joint Committees on Banking and Insurance and Health Services relating to prior authorization in the provision of health care benefits under this chapter. 

(b) The report required under paragraph (a) of this subsection shall include: 

1. Information relating to the implementation and effectuation of KRS 304.17A-606. 

2. The number of insurers and private review agents offering a program required under KRS 304.17A-606; 

3. The number of providers, by provider group, specialty, and county, participating in one (1) or more programs offered under KRS 304.17A606; 

4. A list of health care services, which shall include a description and Current Procedural Terminology code for each service, for which exemptions have been granted under the programs required under KRS 304.17A-606;

5. The number of programs offered under KRS 304.17A-606, which shall include: 

a. The number of programs that grant exemptions for one (1) or more prescription drugs; and 

b. A list of the drugs for which exemptions are granted under a program reported under subdivision a. of this subparagraph; and 

(6) With respect to any health insurance policy, certificate, plan, or contract required to comply with KRS 304.17A-600 to 304.17A-633: 

a. A list of all services, procedures, and other treatments, including prescription drugs, that require prior authorization; 

b. The percentage of prior authorization requests for nonurgent health care services in aggregate and by specific service, procedure, prescription drug, and other treatment: 

i. That were approved without an extension; 

ii. For which the review was extended and the request approved; and 

iii. That were denied, which may include the reason or reasons for the denials; 

c. The percentage of prior authorization requests for urgent health care services that were: 

i. Approved; and 

ii. Denied, which may include the reason or reasons for the denials; and 

d. The average and median time between submission of a prior authorization request and the prior authorization decision for: 

i. Nonurgent health care services; and 

ii. Urgent health care services; 

(2) Provide the Interim Joint Committees on Banking and Insurance and Health Services with a detailed briefing, upon request, to discuss and explain any report submitted under subsection (1) of this section; and 

(3) Promulgate any administrative regulation, including an emergency administrative regulation, in accordance with KRS Chapter 13A that the commissioner deems necessary to implement this section. 

See https://apps.legislature.ky.gov/law/statutes/chapter.aspx?id=38715.

Section 304.17A-607. Duties of insurer or private review agent performing utilization reviews -- Requirement for registration -- Consequences of insurer's failure to make timely utilization review determination -- Requirement that insurer or private review agent submit changes to the department -- Requirement that private review agent provide timely notice of entities for whom it is providing review.  

(1) An insurer or private review agent shall not provide or perform utilization reviews without being registered with the department. 

(2) A registered insurer or private review agent shall: 

(a) Have available the services of sufficient numbers of registered nurses, medical records technicians, or similarly qualified persons supported by licensed physicians with access to consultation with other appropriate physicians to carry out its utilization review activities; 

(b) Ensure that for the provision of utilization review services, only licensed physicians, who are of the same or similar specialty and subspecialty, when possible, as the ordering provider, shall: 

1. Make a utilization review decision to: 

a. Deny, reduce, limit, or terminate a health care benefit; or 

b. Deny, or reduce payment for, a health care service because that service is not medically necessary, experimental, or investigational;

except in the case of a health care service rendered by a chiropractor or optometrist where the denial shall be made respectively by a chiropractor or optometrist duly licensed in Kentucky; and 

2. Supervise qualified personnel conducting case reviews; 

(c) Have available the services of sufficient numbers of practicing physicians in appropriate specialty areas to assure the adequate review of medical and surgical specialty and subspecialty cases; 

(d) Not disclose or publish individual medical records or any other confidential medical information in the performance of utilization review activities except as provided in the Health Insurance Portability and Accountability Act, Subtitle F, secs. 261 to 264 and 45 C.F.R. pts. 160 to 164 and other applicable laws and administrative regulations; 

(e) Provide a toll-free telephone line for covered persons, authorized persons, and providers to contact the insurer or private review agent and be accessible to covered persons, authorized persons, and providers for forty (40) hours a week during normal business hours in this state; 

(f) Where an insurer, its agent, or private review agent provides or performs utilization review, be available to conduct utilization review during normal business hours and extended hours in this state on Monday and Friday through 6:00 p.m., including federal holidays; 

(g) Provide decisions to covered persons, authorized persons, and all providers on appeals of adverse benefit determinations of the insurer or private review agent, in accordance with this section and administrative regulations promulgated in accordance with KRS 304.17A-609; 

State Medical Necessity Decisions - Deadlines/ERISA-Med. Nec. Decisions-Deadlines

(h) Except for retrospective review of an emergency admission where the covered person remains hospitalized at the time the review request is made, which shall be considered a concurrent review, or as otherwise provided in this subtitle, provide a utilization review decision in accordance with the timeframes in paragraph (i) of this subsection and 29 C.F.R. pt. 2560, including written notice of the decision; 

(i)1. Render a utilization review decision concerning urgent health care services, and notify the covered person, authorized person, or provider of that decision no later than twenty-four (24) hours after obtaining all necessary information to make the utilization review decision; and 

2. If the insurer or agent requires a utilization review decision of nonurgent health care services, render a utilization review decision and notify the covered person, authorized person, or provider of the decision within five (5) days of obtaining all necessary information to make the utilization review decision. 

For purposes of this paragraph, "necessary information" is limited to: 

a. The results of any face-to-face clinical evaluation; 

b. Any second opinion that may be required; and 

c. Any other information determined by the department to be necessary to making a utilization review determination; 

(j)1. Provide written notice of review decisions to the covered person, authorized person, and providers. 

2. The written notice may be provided in an electronic format, including email or facsimile, if the covered person, authorized person, or provider has agreed in advance in writing to receive the notices electronically. 

3. An insurer or agent that denies a step therapy exception, as defined in KRS 304.17A-163, or denies coverage or reduces payment for a treatment, procedure, drug that requires prior approval, or device shall include in the written notice: 

a. A statement of the specific medical and scientific reasons for denial or reduction of payment or identifying that provision of the schedule of benefits or exclusions that demonstrates that coverage is not available; 

b. The title of the reviewer making the decision, except that a written notice provided to a provider shall also include, if applicable, the medical license number of the reviewer making the decision; 

c. Except for retrospective review, a description of alternative benefits, services, or supplies covered by the health benefit plan, if any; and 

d. Instructions for initiating or complying with the insurer's internal appeal procedure, as set forth in KRS 304.17A-617, stating, at a minimum: 

i. Whether the appeal shall be in writing; 

ii. Any specific filing procedures, including any applicable time limitations or schedules; and 

iii. The position and phone number of a contact person who can provide additional information; 

(k) Afford participating physicians an opportunity to review and comment on all medical and surgical and emergency room protocols, respectively, of the insurer and afford other participating providers an opportunity to review and comment on all of the insurer's protocols that are within the provider's legally authorized scope of practice; and 

(l) Comply with its own policies and procedures on file with the department or, if accredited or certified by a nationally recognized accrediting entity, comply with the utilization review standards of that accrediting entity where they are comparable and do not conflict with state law. 

(3)(a) The insurer's or private review agent's failure to make a determination and provide written notice within the time frames set forth in this section shall be deemed to be a prior authorization for the health care services or benefits subject to the review. 

(b) This subsection shall not apply where the failure to make the determination or provide the notice results from circumstances which are documented to be beyond the insurer's control. 

(4)(a) An insurer or private review agent shall submit a copy of any changes to its utilization review policies or procedures to the department. 

(b) No change to utilization review policies and procedures shall be effective or used until after it has been filed with and approved by the commissioner. 

(5)(a) A private review agent shall provide to the department the names of the entities for which the private review agent is performing utilization review in this state. 

(b) Notice shall be provided to the department within thirty (30) days of any change. 

See https://apps.legislature.ky.gov/law/statutes/chapter.aspx?id=38715

Section 304.17A-611. Prohibition against retrospective denial of coverage for health care services under certain circumstances (Effective until January 1, 2028)

Retroactive Denial

(1) A utilization review decision shall not retrospectively deny coverage for health care services provided to a covered person when prior approval has been obtained from the insurer or its designee for those services, unless the approval was based upon fraudulent, materially inaccurate, or misrepresented information submitted by the covered person, authorized person, or the provider. 

(2) An insurer of a health benefit plan shall not require or conduct a prospective or concurrent review for a prescription drug: 

(a) That: 

1. Is used in the treatment of alcohol or opioid use disorder; and 

2. Contains Methadone, Buprenorphine, an opioid antagonist, or Naltrexone; or 

(b) That was approved before January 1, 2022, by the United States Food and Drug Administration for the mitigation of opioid withdrawal symptoms. 

See https://apps.legislature.ky.gov/law/statutes/

Section 304.17A-611. Prohibition against retrospective denial of coverage for health care services under certain circumstances (Effective on January 1, 2028)

Retroactive Denial

(1) A utilization review decision shall not retrospectively deny coverage for health care services provided to a covered person when prior approval has been obtained from the insurer or its designee for those services, unless the approval was based upon fraudulent, materially inaccurate, or misrepresented information submitted by the covered person, authorized person, or the provider. 

(2) An insurer of a health benefit plan shall not require or conduct a prospective or concurrent review for a prescription drug: 

(a) That: 

1. Is used in the treatment of alcohol or opioid use disorder; and 

2. Contains Methadone, Buprenorphine, an opioid antagonist, or Naltrexone; or 

(b) That was approved before January 1, 2022, by the United States Food and Drug Administration for the mitigation of opioid withdrawal symptoms. 

(3) Notwithstanding any other law to the contrary: 

(a) An insurer or its private review agent shall not conduct a retrospective review that is based solely on a participating provider having a prior authorization exemption under a program offered under KRS 304.17A-606(3) except to determine if the provider continues to qualify for the exemption; and 

(b) The timeframes for rendering a utilization review decision under KRS 304.17A-607 shall not apply to a retrospective review conducted for the purpose of determining if a participating provider qualifies for an initial or continuing prior authorization exemption under a program offered under KRS 304.17A-606(3). 

See https://apps.legislature.ky.gov/law/statutes/

Section 304.17A-615. Prohibition against denying or reducing payments under certain circumstances. 

(1) No insurer or any other person providing or administering a health benefit plan shall deny or reduce payment for a service, procedure, treatment, drug or device covered under the covered person's health benefit plan if: 

(a) The covered person's provider, during normal business hours, contacts the insurer, the designee, or agent on the day the covered person is expected to be discharged, in order to request review of the covered person's continued hospitalization, and the insurer, designee, or agent fails to provide a timely utilization review decision as required by KRS 304.17A-607; or 

(b) The covered person's provider makes at least three (3) documented attempts during a four (4) consecutive hour period to contact the insurer, designee, or agent, during normal business hours in order to request review of a continued hospital stay, preauthorization of treatment for a covered person who is already hospitalized, or retrospective review of an emergency hospital admission where the covered person remains hospitalized at the time the review requested is made, and the insurer, designee, or private review agent fails to be accessible as required by KRS 304.17A-607. 

(2) The insurer's liability to pay for the covered person's hospitalization under the circumstances set forth in subsection (1) of this section shall extend until the insurer, designee, or private review agent issues a utilization review decision applicable to requests for review relating to matters as set forth in subsection 1(b) of this section. 

(3) The insurer's liability to pay under this section shall be conditioned on: 

(a) The provider establishing verifiable documentation of the contact with, and subsequent failure of the insurer, designee, or agent to make the utilization review decision as set forth in subsection (1)(a) of this section; or 

(b) The provider establishing verifiable documentation of the attempt to make contact with the insurer, designee, or agent as addressed in subsection (1)(b) of this section. 

(4) In either instance, the contact, or attempts to contact, as set forth in this section, shall be made by the means required by the insurer, designee, or agent for requesting utilization review. 

(5) This section applies only when the request for review concerns covered health benefits and it shall not supersede any limitations or exclusions in the covered person's health benefit plan. This section shall not apply if, in requesting a review, the provider does not furnish the information requested by the insurer or agent to make a utilization review decision, or if actions by the provider impede an insurer's or private review agent's ability to issue a utilization review decision. 

See https://apps.legislature.ky.gov/law/statutes/chapter.aspx?id=38715

Section 304.17A-617. Internal appeals process -- Procedures -- Review of coverage denials.             

(1)(a) Every insurer shall have an internal appeal process for adverse benefit determinations that is:

1. Utilized by the insurer or its designee, consistent with this section and KRS 304.17A-619; and 

2. Disclosed to covered persons in accordance with KRS 304.17A505(1)(g). 

(b) An insurer shall disclose the availability of the internal appeal process to the covered person in the insured's timely notice of an adverse benefit determination which meets the requirements in KRS 304.17A-607(2)(j). 

(c) Where a coverage denial is involved, in addition to stating the reason for the coverage denial, the required notice shall contain instructions for filing a request for internal appeal. 

(2) The internal appeals process may be initiated by the covered person, an authorized person, or a provider acting on behalf of the covered person. 

(3) The internal appeals process shall include adequate and reasonable procedures for review and resolution of appeals concerning adverse benefit determinations, including procedures for reviewing appeals from covered persons whose medical conditions require expedited review. 

(4) At a minimum, the procedures required under subsection (3) of this section shall include the following: 

(a) Except as provided in KRS 304.17A-163, insurers or their designees shall provide decisions to covered persons, authorized persons, and providers on internal appeals: 

State Medical Necessity Appeals-Deadlines

1. Within thirty (30) days of receipt of the request for internal appeal, except as provided in subparagraph 2. of this paragraph; or 

2. Not later than three (3) business days after receipt of a request for an expedited appeal of an adverse benefit determination. An expedited appeal is deemed necessary when a covered person is hospitalized or, in the opinion of the treating provider, review under a standard time frame could, in the absence of immediate medical attention, result in any of the following: 

a. Placing the health of the covered person or, with respect to a pregnant woman, the health of the covered person or the unborn child in serious jeopardy; 

b. Serious impairment to bodily functions; or 

c. Serious dysfunction of a bodily organ or part; 

(b) Internal appeal of an adverse benefit determination, other than a coverage denial, shall only be conducted by a licensed physician who did not participate in the initial review and denial, except in the case of a review involving a medical or surgical specialty or subspecialty, the insurer or agent shall, upon request by a covered person, authorized person, or provider, utilize a board-eligible or certified physician in the appropriate specialty or subspecialty area to conduct the internal appeal; 

(c) Those portions of the medical record that are relevant to the internal appeal, if authorized by the covered person and in accordance with state or federal law, shall be considered and providers given the opportunity to present additional information; and 

(d) In addition to any previous notice required under KRS 304.17A-607(2)(j), and to facilitate expeditious handling of a request for external review or review of a coverage denial under subsection (5) of this section, an insurer or agent that denies, limits, reduces, or terminates coverage for a service, treatment, procedure, drug, supply, or device for a covered person shall provide the covered person, authorized person, or provider acting on behalf of the covered person with an internal appeal determination letter that includes: 

1. A statement of the specific medical and scientific reasons for denying coverage or identifying that provision of the schedule of benefits or exclusions that demonstrates that coverage is not available; 

2. As applicable, the state of licensure and the title of the person making the decision, except that an internal appeal determination letter provided to a provider acting on behalf of the covered person shall also include the medical license number of the person making the decision; 

3. Except for retrospective review, a description of alternative benefits, services, or supplies covered by the health benefit plan, if any; and 

4. Instructions for: 

a. Initiating an external review; or 

b. For coverage denials, filing a request for review with the department under subsection (5) of this section. 

(5)(a) The department shall establish and maintain a system for receiving and reviewing requests for review of coverage denials from covered persons, authorized persons, and providers. 

(b) For purposes of this subsection, "coverage denials" shall not include subsequent denials arising from an adverse benefit determination that is not a coverage denial. 

(c) On receipt of a written request for review of a coverage denial from a covered person, authorized person, or provider, the department shall: 

1. Notify the insurer that issued the denial of the request for review; and 

2. Call for the insurer to respond to the department regarding the request for review within ten (10) business days of receipt of notice to the insurer. 

(d) Within ten (10) business days of receiving the notice of the request for review from the department, the insurer shall provide to the department the following information: 

1. Confirmation as to whether the person who received or sought the service, procedure, treatment, drug, supply, or device for which coverage was denied was a covered person under a health benefit plan issued by the insurer on the date the service, procedure, treatment, drug, supply, or device was sought or denied; 

2. Confirmation as to whether the covered person, authorized person, or provider has exhausted his or her rights under the insurer's internal appeal process under this section; and 

3. The reason for the coverage denial, including the specific limitation or exclusion of the health benefit plan demonstrating that coverage is not available. 

(e) In addition to the information described in paragraph (d) of this subsection, the insurer and the covered person, authorized person, or provider shall provide to the department any information requested by the department that is germane to its review. 

(f)1. On the receipt of the information described in paragraphs (d) and (e) of this subsection, unless the department is not able to do so because making a determination requires resolution of a medical issue, it shall determine whether the service, procedure, treatment, drug, supply, or device is specifically limited or excluded under the terms of the covered person's health benefit plan. 

2. If the department determines that the service, procedure, treatment, drug, supply, or device is not specifically limited or excluded, it shall so notify the insurer, and the insurer shall either cover the service, procedure, treatment, drug, supply, or device or afford the covered person an opportunity for external review, where the conditions precedent to the review are present. 

3. If the department notifies the insurer that the service, procedure, treatment, drug, supply, or device is specifically limited or excluded in the health benefit plan, the insurer is not required to cover the service, procedure, treatment, drug, supply, or device or afford the covered person an external review. 

(g) An insurer shall be required to cover the service, procedure, treatment, drug, supply, or device that was denied or provide notification of the right to external review in accordance with paragraph (f) of this subsection whether the covered person has disenrolled or remains enrolled with the insurer. 

(h) If the covered person has disenrolled with the insurer, the insurer shall only be required to provide the service, procedure, treatment, drug, supply, or device that was denied for a period not to exceed thirty (30) days or provide the covered person the opportunity for external review.

See https://apps.legislature.ky.gov/law/statutes/chapter.aspx?id=38715 

Section 304.17A-619. Duty of covered person, authorized person, or provider to provide insurer with new information regarding internal appeal -- Time frame for insurer to render a decision based on new information -- Insurer's failure to make timely determination or provide written notice.     

(1)(a) If the covered person, authorized person, or provider has new clinical information regarding the covered person's internal appeal, he or she shall provide that information to the insurer prior to the initiation of the external review process. 

(b) The insurer shall have five (5) business days from the date of the receipt of the information to render a decision based on the new information. 

(c) If new information is provided in accordance with this subsection, the sixty (60) day time frame for commencing an external review as set forth in KRS 304.17A-623(4), shall not begin to run, until the insurer or its designee renders a decision regarding the new information. 

(2) The insurer's failure to make a determination or provide a written notice within the time frames set forth in KRS 304.17A-617 shall be deemed to be an adverse benefit determination, other than a coverage denial, by the insurer for the purpose of initiating an external review as set forth in KRS 304.17A-623. 

See https://apps.legislature.ky.gov/law/statutes/chapter.aspx?id=38715