RELATES TO:
KRS
205.560(12),
216B.155(2),
304.17A-005,
304.17A-500,
304.17A-545,
304.17A-575,
304.17A-576
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.
KRS
304.17A-545(5) requires the
commissioner to promulgate administrative regulations to establish a uniform
application form and guidelines for the evaluation and reevaluation of health
care providers, including psychologists, who will be on a managed care plan's
list of participating providers. This administrative regulation establishes the
uniform application form and guidelines for evaluation and reevaluation of a
health care provider, including a psychologist.
Section 1. Definitions.
(1) "Applicant" is defined by
KRS
304.17A-575(1).
(2) "Evaluation" or "credentialing" means:
(a) A process for collecting and verifying
professional qualifications of a health care provider;
(b) An assessment of a health care provider's
professional competence and conduct; and
(c) A process to be completed before a health
care provider may participate in a provider network of an insurer on an initial
or ongoing basis.
(3)
"Form KAPER-1" means the uniform application for credentialing or
recredentialing of a health care provider pursuant to
KRS
304.17A-545(5).
(4) "
Health care provider" or "
provider"
means a:
(a) Health care provider pursuant to
KRS
304.17A-005(23);
or
(b) Psychologist licensed under
KRS Chapter 319.
(5)
"Participating health care provider" means a participating health care provider
pursuant to
KRS
304.17A-500(10), including a
psychologist licensed under KRS Chapter 319.
(6) "Reevaluation" or "recredentialing"
means:
(a) A process for collecting and
reverifying professional qualifications of a participating health care
provider; and
(b) An assessment of
a participating health care provider's professional competence and
conduct.
Section
2. Guidelines for an Insurer.
(1) Except as established in subsection
(3)(b) of this section, an insurer that offers a managed care plan and performs
credentialing or recredentialing activities shall use Form KAPER-1, Part A to
credential or recredential a health care provider who desires participation in
its provider network.
(2) Pursuant
to subsection (1) of this section, an insurer shall:
(a) Have a mechanism for making available and
accepting from a
health care provider a handwritten or electronically submitted
Form KAPER-1, Part A for:
1. Initial
credentialing; and
2.
Recredentialing;
(b)
Within thirty (30) days of receipt of a Form KAPER-1, Part A, electronically or
in writing:
1. Notify the health care
provider of receipt of the Form KAPER-1 and, if applicable, of any omitted or
questionable information included on the form;
2. Offer assistance to the provider, if
requested; and
(c)
1. Within sixty (60) days of receipt of a
Form KAPER-1, Part A, provide an electronic or written notification regarding
the status of credentialing to the health care provider; and
2. Extend the time period identified in
section 2(2)(c)1, due to extenuating circumstances if:
a. Additional time is required by the insurer
to consider information submitted on the Form KAPER-1, Part A; and
b. The health care provider is informed of
the need for more time, including information relating to the extenuating
circumstance, which caused the delay;
(d) Provide electronic or written
notification as established in paragraph (c) of this subsection every thirty
(30) days after the initial notification until a final determination regarding
cre-dentialing has been issued to the health care provider;
(e) Not require:
1. Information on the Form KAPER-1, Part A,
which is not relevant to the scope of practice, health care setting, or service
of the health care provider; and
2.
Routine recredentialing of a health care provider more frequently than three
(3) years from the previous credentialing date; and
(f) Upon making a final determination
regarding credentialing of an applicant in accordance with
KRS
304.17A-576(1), provide
notification of the determination to the applicant.
(3) An insurer may use:
(a) Form KAPER-1, Part A to credential or
recredential an individual in its provider network other than a health care
provider; and
(b) The provider
credentialing application form of the Council for Affordable Quality Healthcare
as identified in the introduction of the Form KAPER-1, Part A, in lieu of the
Form KAPER-1, Part A.
Section 3. Incorporation by Reference.
(1) The "Kentucky Application for Provider
Evaluation and Reevaluation", Form KAPER-1 (10/2021), is incorporated by
reference.
(2) This material may be
inspected, copied, or obtained, subject to applicable copyright law, at the
Department of Insurance, 500 Mero St., 2SE11, Frankfort, Kentucky 40601, Monday
through Friday, 8 a.m. to 4:30 p.m. This material is also available on the
Department of Insurance Web site at:
http://insurance.ky.gov.
