Section 304.17A-613 - Emergency administrative regulations governing registration of insurers and private review agents seeking to conduct utilization reviews - Procedure for handling complaints(1) The department shall, through the promulgation of emergency administrative regulations, develop a process:(a) For the review of applications for registration of insurers or private review agents seeking to conduct utilization reviews;(b) For the review of applications for insurers or private review agents seeking registration renewal to continue as a utilization review entity;(c) Ensuring that no registration shall be approved unless the commissioner has documentation or findings that all applicants seeking registration or renewal to conduct utilization review are in compliance with the requirements and procedures established regarding utilization review, and as to renewals, have complied with KRS 304.17A-600 to 304.17A-633 and administrative regulations promulgated to enforce and to administer KRS 304.17A-600 to 304.17A-633; and(d) Establishing fees for applications and renewals in an amount sufficient to pay the administrative costs of the program and any other costs associated with carrying out the provisions of KRS 304.17A-600, 304.17A-603, 304.17A-605, 304.17A-607, 304.17A-609, 304.17A-611, 304.17A-613, and 304.17A-615.(2) The registration issued in accordance with this section expires on the second anniversary of the effective date unless it is renewed.(3) The registration issued under this section is not transferable.(4) The commissioner may revoke or suspend the utilization review registration of any insurer or private review agent who does not comply with the requirements and procedures established regarding utilization review or any administrative regulations promulgated thereunder.(5) The department shall establish reporting requirements to:(a) Evaluate the effectiveness of insurers and private review agents; and(b) Determine if the utilization review plans are in compliance with the requirements and procedures established regarding utilization review and applicable administrative regulations.(6) Upon request of any provider, authorized person, or covered person whose care is subject to review, the department shall provide copies of policies or procedures of any insurer or private review agent that has been issued a registration by the department to conduct review in this state.(7) Notwithstanding any provision to the contrary, an insurer or private review agent registered and in good standing under the provisions of KRS 211.461 to 211.466, prior to July 14, 2000, shall be deemed in compliance with requirements and procedures established in KRS 304.17A-600 to 304.17A-633 regarding utilization review and registered accordingly.(8) Upon receipt of written complaints from covered persons, authorized persons, or providers stating that an insurer or a private review agent has failed to perform a review in accordance with the utilization review plan or the requirements and procedures established regarding utilization review, or administrative regulations promulgated thereunder, the commissioner shall:(a) Send a copy of the complaint to the insurer or the private review agent within ten (10) days of receipt of the complaint, and require that any written reply be sent to the commissioner within ten (10) days; and(b) Review the complaint and any written reply received from the insurer or private review agent within the time frames set forth in paragraph (a) of this subsection and make a recommendation to the insurer or private review agent and the covered person, authorized person, or provider.(9) The commissioner shall consider complaints before issuing or renewing any registration or renewal of a registration to an insurer or a private review agent.(10) Notwithstanding any provision in this section to the contrary, the department shall accept accreditation or certification by a nationally recognized accreditation organization as sufficient documentation or finding for purposes of subsections (1) and (5) of this section that the insurer or private review agent meets the application requirements for registration or renewal. Insurers or private review agents accredited or certified by a nationally recognized accreditation organization shall be deemed compliant with the utilization review and internal appeals requirements of this section and KRS 304.17A-600, 304.17A-607, 304.17A-609, 304.17A-617, 304.17A-623, and 304.17A-625 and administrative regulations to the extent the standards of such nationally recognized accreditation organization sufficiently meet these requirements. The department shall have a simplified process in administrative regulations for insurers and private review agents to register using accreditation or certification and shall limit any additional documentation only for demonstrating compliance with requirements in this section and KRS 304.17A-600, 304.17A-607, 304.17A-609, 304.17A-617, 304.17A-623, and 304.17A-625 not met by the standards of a nationally recognized accreditation organization.Effective:7/15/2010
Amended 2010, Ky. Acts ch. 24, sec. 1238, effective7/15/2010. -- Amended 2002, Ky. Acts ch. 181, sec. 7, effective 7/15/2002. -- Created 2000, Ky. Acts ch. 262, sec. 7, effective 7/14/2000.