RELATES TO:
KRS
304.17A-540,
304.17A-545,
304.17A-600
- 304.17A-619
NECESSITY, FUNCTION, AND CONFORMITY:
KRS
304.2-110(1) authorizes the
Commissioner to promulgate reasonable administrative regulations necessary for,
or as an aid to, the effectuation of any provision of the Kentucky Insurance
Code, as defined in
KRS
304.1-010. This administrative regulation
establishes the procedure to be followed when a medical director's signature is
required on health care benefit denials.
Section
1. Definitions.
(1) "Adverse
determination" is defined by
KRS
304.17A-600(1).
(2) "Coverage denial" is defined by
KRS
304.17A-617(1).
(3) "Electronic signature" is defined by
KRS
369.102(8).
(4) "Enrollee" is defined by
KRS
304.17A-500(5).
(5) "Managed care plan" is defined by
KRS
304.17A-500(9).
(6) "Medical director" means a person meeting
the requirements of
KRS
304.17A-545(1), and includes
a medical director of an entity under contract and delegated to perform
utilization review on behalf of a managed care plan.
(7) "Notice of coverage denial" means a
letter, a notice, or an Explanation of Benefits statement advising of a
coverage denial as defined by
KRS
304.17A-617(1).
(8) "Signature" means name, title, state of
licensure and license number.
(9)
"Utilization review" is defined by
KRS
304.17A-600(17).
Section 2. Application. This
administrative regulation shall apply to all managed care plans authorized by
law to engage in managed care in the state of Kentucky, and any utilization
review entities registered in Kentucky that have contracted with a managed care
plan to perform utilization reviews on the plan's behalf.
Section 3. Appointment of Medical Director.
(1) A managed care plan shall submit to the
department a:
(a) Completed Form HIPMC-MD-1;
and
(b) Biographical resume of each
individual who shall serve as the medical director.
(2) A managed care plan shall furnish the
department with any change in medical director within thirty (30) days of the
change.
(3) A managed care plan
shall provide for an alternative medical director to serve if the medical
director is absent and furnish the department with information as required in
subsection (1) of this section.
Section 4. Letters of Denial for Adverse
Determination or Notices of Coverage Denial.
(1) Letters of denial for adverse
determination or notices of coverage denial shall be sent to an enrollee's last
known address with a copy of the same sent to the provider.
(2) Letters of denial requiring signature of
the medical director pursuant to
KRS
304.17A-545(1)(d) and
KRS
304.17A-607(1) shall
include:
(a) Letters of adverse determination,
including denials, limitations, reductions and terminations of services, based
on lack of medical necessity; and
(b) Letters of adverse determination,
including denials, limitations, reductions and terminations or services, based
on lack of medical appropriateness.
(3) Notices of coverage denial shall not
require the medical director's signature.
Section 5. Signature of the Medical Director.
For purposes of this administrative regulation, the signature of the medical
director shall include:
(1) Handwritten and
copies of original signature; or
(2) An electronic signature.
Section 6. Incorporation by
Reference.
(1) "Medical Director Report Form",
Form HIPMC-MD-1, 03/2021 is incorporated by reference.
(2) This material may be inspected, copied,
or obtained, subject to applicable copyright law, at the Kentucky Department of
Insurance, The Mayo-Underwood Building, 500 Mero Street, Frankfort, Kentucky
40601, Monday through Friday, 8 a.m. to 4:30 p.m. This material is also
available on the Department's Web site at
http://insurance.ky.gov/ppc/CHAPTER.aspx.