KRS § 205.8455 — KY Code / Title XVII / Chapter 205 / Section 205.8455
205.8455 Recipient Utilization Review Committee -- Authority
Status: in_force

205.8455 Recipient Utilization Review Committee -- Authority.

(1) To implement provisions of this section, the commissioner of the Department for

Medicaid Services shall create, no later than July 30, 1994, a Recipient Utilization

Review Committee with the authority to:

(a) Review individual recipient utilization or program benefits, recipient medical

records, and other additional information or data necessary to make a

decision;

(b) Determine if a recipient has utilized the program or services in a fraudulent or

abusive manner;

(c) Refer cases of suspected recipient fraud to the Office of the Inspector General

in the Cabinet for Health and Family Services;

(d) Institute administrative actions to restrict or revoke the recipient's

participation in the Medical Assistance Program; and

(e) Initiate actions to recover the value of benefits received by the recipient which

were determined to be related to fraudulent or abusive activities.

(2) The Recipient Utilization Review Committee shall be composed of five (5)

members as follows: one (1) licensed physician, one (1) representative from the

same program benefit area that is the subject of the review, one (1) recipient or

representative of medical assistance benefits, one (1) representative of the

Surveillance and Utilization Review Subsystems Unit, as required under Title XIX

of the Social Security Act, and the commissioner of the Department for Public

Health, who shall serve by virtue of his or her office.

(3) A medical assistance recipient whose eligibility has been revoked due to defrauding

the Medical Assistance Program shall not be eligible for future medical assistance

services for a period of not more than one (1) year or until full restitution has been

made to the Department for Medicaid Services, whichever comes first.

(4) When a medical assistance recipient whose eligibility has been revoked due to

defrauding of the Medical Assistance Program reapplies for coverage, during the

period of revocation, due to pregnancy, a communicable disease, or other condition

that creates a risk to public health, or a condition which if not treated could result in

immediate grave bodily harm, the recipient utilization review committee for the

Department for Medicaid Services may change the revoked status of the previously

eligible recipient to restricted status if it has been determined that it would be in the

best interest of the previously eligible medical assistance recipient to receive

coverage for medical assistance services and the person is otherwise eligible. If this

change in status is granted, the case shall be reconsidered by the Recipient

Utilization Review Committee within sixty (60) days after the restricted status takes

effect.

(5) Upon determination by the Recipient Utilization Review Committee of the

Department for Medicaid Services that a medical assistance recipient has abused the

benefits of the Medical Assistance Program, the recipient shall immediately be

assigned and restricted to a managed care primary physician designated by the

Department for Medicaid Services. Except in the case of an emergency as defined

by the recipient utilization review committee and set forth by the Cabinet for Health

and Family Services in an administrative regulation promulgated pursuant to KRS

Chapter 13A, the restricted recipient shall be eligible to receive covered services

only upon presenting to a participating provider, prior to the receipt of services, a

dated written referral by the assigned managed care primary physician. Any

participating provider who provides services to a medical assistance recipient in

violation of the provisions of this subsection shall not be eligible for reimbursement

for any services rendered.

(6) The Cabinet for Health and Family Services shall request any waivers of federal law

that are necessary to implement the provisions of this section.

(7) The provisions of paragraphs (d) and (e) of subsection (1) of this section and of

subsections (3), (4), and (5) of this section shall have no force or effect until and

unless the requested waivers are granted.

(8) Nothing in this section shall authorize the Cabinet for Health and Family Services

to waive the recipient's or provider's rights to prior notice and hearing as guaranteed

by federal law.

(9) All complaints received by the Department for Medicaid Services, the Office of the

Inspector General, the Office of the Attorney General, or by personnel of the

Cabinet for Health and Family Services concerning possible fraud or abuse by a

medical assistance recipient shall be forwarded immediately to the Recipient

Utilization Review Committee for its consideration. Any cases of possible recipient

fraud or abuse uncovered by personnel of the Cabinet for Health and Family

Services or by providers shall also be referred immediately to the Recipient

Utilization Review Committee for its review. Records shall be kept of all cases,

including records of disposition, considered by the Recipient Utilization Review

Committee.