§ 304-18-045

304.1 8-045 Requirements for insurer that issues policy or administers program providing for utilization review of benefits. (1) Every health insurer proposing to issue or deliver in this state a group or blanket health insurance policy or contract or administ er a health benefit program which provides for the coverage of hospital benefits and the utilization review of those benefits by an insurer, its designee, or a private review agent shall: (a) Be registered in accordance with KRS 304.17A -607 and administrat ive regulations promulgated under the authority of KRS 304.17A -613; or (b) Contract with a private review agent that has been registered in accordance with KRS 304.17A -607 and administrative regulations promulgated under the authority of KRS 304.17A -613. (2) Notwithstanding any other provision of KRS 304.17A -603, 304.17A -605, 304.17A - 607, 304.17A -609, 304.17A -611, 304.17A -613, and 304.17A -615, an insurer or its designee shall not deny or reduce payment of health benefits to any person, licensed practitioner , or health facility for covered services which have been rendered to an insured unless: (a) Notice of denial has been issued.

r reduce payment of health benefits to any person, licensed practitioner , or health facility for covered services which have been rendered to an insured unless: (a) Notice of denial has been issued. The notice shall inform patients, authorized persons, and health -care providers of their right to appeal adverse determinations o f a utilization review by the insurer, its designee, or private review agent to the insurer for the internal review process established by the insurer in accordance with KRS 304.17A -617 and 304.17A -619. The notice shall also include instructions on filing an internal appeal; and (b) The insurer is in compliance with subsection (1) of this section. Effective: July 14, 2000 History: Amended 2000 Ky. Acts ch. 262, sec. 28, effective July 14, 2000. -- Amended 1998 Ky. Acts ch. 426, sec. 526, effective July 15, 1998. -- Amended 1996 Ky. Acts ch. 353, sec. 2, effective July 15, 1996. -- Created 1990 Ky. Acts ch. 451, sec. 8, effective July 13, 1990.