Kentucky Administrative Regulations › Title 803 - LABOR CABINET › Chapter 25 - Department of Workers' Claims › Section 803 KAR 25:190 - Utilization review - Medical Bill Audit - Medical Director - Appeal of Utilization Review Decisions

Current through Register Vol. 51, No. 1, July 1, 2024
RELATES TO: KRS Chapter 342
NECESSITY, FUNCTION, AND CONFORMITY:
				KRS
				342.260 provides that the Commissioner of the
				Department of Workers' Claims shall 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) provides that the
				commissioner of the Department of Workers' Claims shall 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 adopted to insure compliance with the medical
				fee schedule provisions of
				KRS
				342.035(1) and (4).
				KRS
				342.035(5) also 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(6) allows the
				commissioner to promulgate regulations incorporating managed care or other
				concepts intended to reduce costs or to speed the delivery of payment of
				medical services to employees receiving medical and related benefits under KRS
				Chapter 342. This administrative regulation insures that insurance carriers,
				group self-insurers, and individual self-insured employers implement a
				utilization review and audit program and establishes a medical director to
				speed the delivery of payment of medical services to employees receiving
				medical and related benefits under this chapter. This administrative regulation
				does not abrogate the right, as provided in
				KRS
				342.020, of an injured employee to choose his
				treating physician, or an employer to participate in a managed health care
				system.
Section 1. Definitions.
(1) "Business day" means any day except
			 Saturday, Sunday or any day which 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 which have been provided to assure compliance with
			 adopted fee schedules.
(8) "Medical
			 Director" means the Medical Director of the Department of Workers' Claims
			 appointed by the Secretary.
(9)
			 "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. .
(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)
			 "Secretary" means the Secretary of the Kentucky Labor Cabinet.
(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 carrier describing the procedures governing utilization
			 review and medical bill audit activities.
(16) "Vendor" means a person or entity which
			 implements a utilization review and medical bill audit program for purposes of
			 offering those services to carriers.