Kentucky Administrative Regulations › Title 806 - PUBLIC PROTECTION CABINET - DEPARTMENT OF INSURANCE › Chapter 17 - Health Insurance Contracts › Section 806 KAR 17:280 - Registration, utilization review, and internal appeal

Current through Register Vol. 51, No. 1, July 1, 2024
RELATES TO:
				KRS
				217.211,
				304.2-140,
				304.2-310,
				304.17-412,
				304.17A-005,
				304.17A-163,
				304.17A-1631,
				304.17A.167,
				304.17A-168,
				304.17A-535,
				304.17A-600,
				304.17A-607,
				304.17A-619,
				304.17A-623,
				304.17C-010,
				304.17C-030,
				304.18-045,
				304.32-147,
				304.32-330,
				304.38-225,
				304.47-050
NECESSITY, FUNCTION, AND CONFORMITY:
				KRS
				304.2-110(1) authorizes the
				Commissioner to promulgate reasonable 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-609 requires the department to
				promulgate administrative regulations regarding utilization review and internal
				appeal and KRS
				304.17A-1631 requires the commissioner to
				promulgate administrative regulations regarding step therapy protocols and
				exceptions. KRS
				304.17A-613 requires the department to
				promulgate administrative regulations to develop a process for the registration
				of insurers or private review agents. This administrative regulation
				establishes requirements for the registration of insurers or private review
				agents, and the utilization review process, including internal appeal of
				decisions and step therapy exception request denials.
Section 1. Definitions.
(1) "Adverse determination" is defined by
			 KRS
			 304.17A-600(1).
(2) "Authorized person" is defined by
			 KRS
			 304.17A-600(2).
(3) "Board" means one (1) of the following
			 governing bodies:
(a) The American Board of
			 Medical Specialties;
(b) The
			 American Osteopathic Association; or
(c) The American Board of Podiatric
			 Surgery.
(4) "Coverage
			 denial" is defined by
			 KRS
			 304.17A-617(1).
(5) "Department" means Department of
			 Insurance.
(6) "Enrollee" is
			 defined by KRS
			 304.17C-010(2).
(7) "Health benefit plan" is defined by
			 KRS
			 304.17A-005(22).
(8) "Health Care Provider" or "provider" is
			 defined in KRS
			 304.17A-005(23) and includes
			 pharmacy as required under
			 806 KAR 17:580.
(9) "Insurer" is defined by
			 KRS
			 304.17A-005(29).
(10) "Internal appeals process" is defined by
			 KRS
			 304.17A-600(9).
(11) "Limited health service benefit plan" is
			 defined by KRS
			 304.17C-010(5).
(12) "Nationally recognized accreditation
			 organization" is defined by
			 KRS
			 304.17A600(10).
(13) "Notice of coverage denial" means a
			 letter, a notice, or an explanation of benefits statement advising of a
			 coverage denial.
(14) "Policies and
			 procedures" means the documentation which outlines and governs the steps and
			 standards used to carry out functions of a utilization review
			 program.
(15) "Private review
			 agent" is defined by KRS
			 304.17A-600(11).
(16) "Registration" is defined by
			 KRS
			 304.17A-600(14).
(17) "Step therapy exception" is defined in
			 KRS
			 304.17A-163(1)(f).
(18) "Step therapy protocol" is defined in
			 KRS
			 304.17A-163(1)(g).
(19) "Utilization review" is defined by
			 KRS
			 304.17A-600(17).
(20) "Utilization review plan" is defined by
			 KRS
			 304.17A-600(18).