Kentucky Administrative Regulations › Title 803 - LABOR CABINET › Chapter 25 - Department of Workers' Claims › Section 803 KAR 25:195 - Utilization review, appeal of utilization review decisions, and medical bill audit

Current through Register Vol. 51, No. 1, July 1, 2024
RELATES TO: KRS Chapter 342
NECESSITY, FUNCTION, AND CONFORMITY:
				KRS
				342.260 requires the Commissioner of the
				Department of Workers' Claims to promulgate administrative regulations
				necessary to carry on the work of the Department of Workers' Claims, and the
				commissioner may promulgate administrative regulations not inconsistent with
				the provisions of KRS Chapter 342.
				KRS
				342.035(5) requires the
				commissioner to promulgate administrative regulations governing medical
				provider utilization review activities conducted by an insurance carrier, group
				self-insurer, or self-insured employer pursuant to KRS Chapter 342.
				KRS
				342.035(5) requires the
				Commissioner of the Department of Workers' Claims to promulgate administrative
				regulations that require each insurance carrier, group self-insurer, and
				individual self-insured employer to certify to the commissioner the program it
				has established to ensure compliance with the medical fee schedule provisions
				of KRS
				342.035(1) and (4).
				KRS
				342.035(8) requires the
				commissioner to establish or develop a pharmaceutical formulary and treatment
				guidelines. This administrative regulation establishes provisions to ensure
				that insurance carriers, group self-insurers, and individual self-insured
				employers implement a utilization review and medical bill audit program.
Section 1. Definitions.
(1) "Business day" means any day except
			 Saturday, Sunday, or any day that is a legal holiday.
(2) "Calendar day" means all days in a month,
			 including Saturday, Sunday and any day which is a legal holiday.
(3) "Carrier" is defined by
			 KRS
			 342.0011(6).
(4) "Commissioner" is defined by
			 KRS
			 342.0011(9).
(5) "Denial" means a determination by the
			 utilization reviewer that the medical treatment, proposed treatment, service,
			 or medication under review is not medically necessary or appropriate and,
			 therefore, payment is not recommended.
(6) "Department" is defined by
			 KRS
			 342.0011(8).
(7) "Medical bill audit" means the review of
			 medical bills for services that have been provided to assure compliance with
			 adopted fee schedules.
(8)
			 "Medically necessary" or "medical necessity" means healthcare services,
			 including medications, that a medical provider, exercising prudent clinical
			 judgment, would provide to a patient for the purpose of preventing, evaluating,
			 diagnosing, or treating, an illness, injury, disease, or its symptoms, and that
			 are:
(a) In accordance with generally
			 accepted standards of medical practice;
(b) Clinically appropriate, in terms of type,
			 frequency, extent site and duration; and
(c) Considered effective for the patient's
			 illness, injury, or disease.
(9) "Medical payment obligor" means any
			 self-insured employer, carrier, insurance carrier, self-insurer, or any person
			 acting on behalf of or as an agent of the self-insured employer, carrier,
			 insurance carrier, or self-insurer.
(10) "Medical provider" means physicians and
			 surgeons, psychologists, optometrists, dentists, podiatrists, osteopathic and
			 chiropractic practitioners, physician assistants, and advanced practice
			 registered nurses, acting within the scope of their license
(11) "Physician" is defined by
			 KRS
			 342.0011(32).
(12) "Preauthorization" means a process
			 whereby payment for a medical service or course of treatment is assured in
			 advance by a carrier.
(13) "Same
			 medical specialty" means a branch of medical practice focused regularly and
			 routinely on a defined group of patients, diseases, skills, body parts, or
			 types of injury and performed by a physician with the same or similar
			 qualifications.
(14) "Utilization
			 review" means a review of the medical necessity and appropriateness of medical
			 care and services for purposes of recommending payments for a compensable
			 injury or disease.
(15)
			 "Utilization review and medical bill audit plan" means the written plan
			 submitted to the commissioner by each medical payment obligor describing the
			 procedures governing utilization review and medical bill audit
			 activities.
(16) "Vendor" means a
			 person or entity that implements a utilization review and medical bill audit
			 program for purposes of offering those services to carriers.