§ 304-17a-540

304.17A -540 Disclosure of limitations on coverage -- Denial letter. (1) Any insurer that limits coverage for any treatment, procedure, a drug, or device shall define the limitations and fully disclose those limits in the health insurance policy or certificate coverage. (2) (a) Any insurer that denies coverage for a treatment, procedure, a drug that requires prior approval, or device for an enrollee shall provide the enrollee with a denial letter that shall include: 1. The name, license number, state of licensure, and title of the person making the decision; 2. A statement setti ng forth the specific medical and scientific reasons for denying coverage of a service, if the coverage is denied for reasons of medical necessity; and 3. Instructions for initiating or complying with the plan's grievance or appeal procedure stating at a m inimum whether the appeal must be in writing, any time limitations or schedules for filing appeals and the name and phone number of a contact person who can provide additional information. (b) The denial letter shall be provided within: 1. Two (2) regular working days of the submitted request where preauthorization for a treatment, procedure, drug, or

an provide additional information. (b) The denial letter shall be provided within: 1. Two (2) regular working days of the submitted request where preauthorization for a treatment, procedure, drug, or device is involved; 2. Twenty -four (24) hours of the submitted request where hospital preadmission review is sought; 3. Twenty (20) working days of the receip t of requested medical information where the plan has initiated a retrospective review; and 4. Twenty (20) working days of the initiation of the review process in all other instances. Effective: July 14, 2000 History: Amended 2000 Ky. Acts ch. 500, sec. 6, effective July 14, 2000. -- Created 1998 Ky. Acts ch. 496, sec. 33, effective April 10, 1998.