Kentucky Administrative Regulations › Title 806 - PUBLIC PROTECTION CABINET - DEPARTMENT OF INSURANCE › Chapter 17 - Health Insurance Contracts › Section 806 KAR 17:290 - Independent External Review Program

Current through Register Vol. 51, No. 1, July 1, 2024
RELATES TO: KRS 304.1-050, 304.2-100, 304.2-230, 304.2-310,
				304.17A-005, 304.17A-163, 304.17A-1631, 304.17A-168, 304.17A-505, 304.17A-535,
				304.17A-600, 304.17A-607, 304.17A-617, 304.17A-621-304.17A-631
NECESSITY, FUNCTION, AND CONFORMITY: KRS 304.2-110(1)
				authorizes the commissioner to promulgate administrative regulations necessary
				for or as an aid to the effectuation of any provision of the Kentucky Insurance
				Code as defined in KRS 304.1-010. KRS 304.17A-629 requires the department to
				promulgate administrative regulations regarding the Independent External Review
				Program, and KRS 304.17A-1631 requires the commissioner to promulgate
				administrative regulations regarding step therapy protocols and exceptions.
				This administrative regulation establishes the insurer requirements, procedures
				for the certification of independent review entities, and the process for
				initiating and conducting external review of utilization review decisions and
				step therapy exception internal appeal denials. This administrative regulation
				also establishes the disclosure requirements of the external review process to
				be included in the health benefit plan issued at enrollment of a covered
				person.
Section 1. Definitions.
(1) "Adverse determination" is defined by KRS 304.17A-600(1).
(2) "Assign" or
			 "assignment" means selection of an independent review entity by an insurer, and
			 acceptance of a request to conduct an external review by an independent review
			 entity.
(3) "Authorized person" is
			 defined by KRS 304.17A-600(2).
(4)
			 "Commissioner" is defined by KRS 304.1-050(1).
(5) "Coverage denial" is defined by KRS 304.17A-617(1)(c).
(6) "Covered
			 person" means:
(a) A covered person as defined
			 by KRS 304.17A-600(4); and
(b) As
			 used in:
1. Sections 2 and 3 of this
			 administrative regulation, insureds subject to a step therapy protocol
			 established by an insurer, health plan, pharmacy benefit manager, or private
			 review agent subject to KRS 304.17A-163; and
2. Section 5(2)(b) of this administrative
			 regulation, insureds seeking an external review under KRS 304.17A-163;
(7) "Department" is defined by KRS 304.1-050(2).
(8) "External review"
			 is defined by KRS 304.17A-600(5).
(9) "Financial hardship" means the:
(a) Gross income of the covered person is
			 below 200 percent of the federal poverty level based upon family size as shown
			 by a federal income tax return for the previous year; or
(b) Covered person's participation in one (1)
			 of the following programs:
1. National
			 Prescription Drug Patient Assistance;
2. Kentucky Transitional Assistance Program
			 (K-TAP);
3. Kentucky Medical
			 Assistance Program; or
4.
			 Unemployment Insurance.
(10) "Health care provider" or "provider" is
			 defined by KRS 304.17A-005(23) and includes pharmacy as required by  806 KAR 17:580.
(11) "Independent review
			 entity" is defined by KRS 304.17A-600(7).
(12) "Insurer" means:
(a) An insurer as defined by KRS 304.17A-600(8); and
(b) Insurers,
			 health plans, pharmacy benefit managers, and private review agents subject to
			 KRS 304.17A-163.
(13)
			 "Reviewer" means an individual selected by the independent review entity to
			 conduct an external review and make a recommended decision to the independent
			 review entity.
(14) "Step therapy
			 exception" is defined by KRS 304.17A-163(1)(f).
(15) "Step therapy protocol" is defined by
			 KRS 304.17A-163(1)(g).