§ 304-32-147

304.3 2-147 Requirements for health service corporation that issues policy or administers program providing for utilization review of benefits. (1) Every nonprofit hospital, medical -surgical, dental, and health service corporation proposing to issue or deliver in this state a health insurance policy or contract or administer a health benefit program which provides for the coverage of hospital benefits and the utilization review of those benefits by a private review agent shall: (a) Be a registered private revie w agent in accordance with KRS 304.17A -607 and administrative 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 regulat ions 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, a nonprofit hospital, medical -surgical, dental, and healt h service corporation shall not deny or reduce payment of health benefits to any person, licensed practitioner, or health facility for covered services

hospital, medical -surgical, dental, and healt h service corporation 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. The notice shall in form patients, authorized persons, and health -care providers of their right to appeal adverse determinations of a utilization review by the insurer, its designee, or private review agent to the insurer for the internal appeal 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 appeal to the cabinet; and (b) The nonprofit hospital, medical -surgical, dental, and health service corporation is in compliance with subsectio n (1) of this section. Effective: July 14, 2000 History: Amended 2000 Ky. Acts ch. 262, sec. 29, effective July 14, 2000. -- Amended 1998 Ky. Acts ch. 426, sec. 527, effective July 15, 1998. -- Amended 1996 Ky. Acts ch. 353, sec. 3, effective July 15, 1996 . -- Created 1990 Ky. Acts ch. 451, sec. 9, effective July 13, 1990.