Title XXV, Business and Financial Institutions
21 chapters · 2,855 sections in this title.
KRS § 304.17A-605 Requirements and procedures for utilization review -- Exception for private review agent operating under contract with the federal government. (Effective until January 1, 2028)
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private review agent operating under contract with the federal government. (Effective until January 1, 2028) (1) KRS 304.17A-600, 304.17A-603, 304.17A-605, 304.17A-607, 304.17A-609, 304.17A-611, 304.17A-613, and 304.17A-615 set forth the requirements and procedures regarding util…
KRS § 304.17A-606 Definitions for section -- Prior authorization exemption program -- Program requirements and options. (Effective January 1, 2028)
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Program requirements and options. (Effective January 1, 2028) (1) As used in this section: (a) "Covered health care service" means a health care service furnished or proposed to be furnished to a covered person that is specifically available or included as a covered benefit in th…
KRS § 304.17A-6061 Commissioner to report to the Legislative Research Commission on prior authorization exemption program -- Contents of report. (Effective January 1, 2028)
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prior authorization exemption program -- Contents of report. (Effective January 1, 2028) The commissioner shall: (1) (a) Submit a written report not later than September 30 of each year to the Legislative Research Commission for referral to the Interim Joint Committees on Banking…
KRS § 304.17A-607 Duties of insurer or private review agent performing utilization reviews -- Requirement for registration -- Consequences of insurer's failure to make timely utilization review determination -- Requirement that insurer or private review agent submit changes to the department -- Requirement that private review agent provide timely notice of entities for whom it is providing review
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reviews -- Requirement for registration -- Consequences of insurer's failure to make timely utilization review determination -- Requirement that insurer or private review agent submit changes to the department -- Requirement that private review agent provide timely notice of enti…
KRS § 304.17A-609 Emergency administrative regulations governing utilization review and internal appeal to be promulgated by the department
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and internal appeal to be promulgated by the department. The department shall promulgate emergency administrative regulations regarding utilization review and internal appeal, including the specification of information required of insurers and private review agents which shall, a…
KRS § 304.17A-611 Prohibition against retrospective denial of coverage for health care services under certain circumstances -- Prohibition against prospective or concurrent review of prescription drug for alcohol or opioid use disorder. (Effective until January 1, 2028)
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services under certain circumstances -- Prohibition against prospective or concurrent review of prescription drug for alcohol or opioid use disorder. (Effective until January 1, 2028) (1) A utilization review decision shall not retrospectively deny coverage for health care servic…
KRS § 304.17A-613 Emergency administrative regulations governing registration of insurers and private review agents seeking to conduct utilization reviews -- Procedure for handling complaints
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insurers and private review agents seeking to conduct utilization reviews -- Procedure for handling complaints. (1) The department shall, through the promulgation of emergency administrative regulations, develop a process: (a) For the review of applications for registration of in…
KRS § 304.17A-615 Prohibition against denying or reducing payments under certain circumstances
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circumstances. (1) No insurer or any other person providing or administering a health benefit plan shall deny or reduce payment for a service, procedure, treatment, drug or device covered under the covered person's health benefit plan if: (a) The covered person's provider, during…
KRS § 304.17A-617 Internal appeals process -- Procedures -- Review of coverage denials
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(1) (a) Every insurer shall have an internal appeal process for adverse benefit determinations that is: 1. Utilized by the insurer or its designee, consistent with this section and KRS 304.17A-619; and 2. Disclosed to covered persons in accordance with KRS 304.17A- 505(1)(g). (b)…
KRS § 304.17A-619 Duty of covered person, authorized person, or provider to provide insurer with new information regarding internal appeal -- Time frame for insurer to render a decision based on new information -- Insurer's failure to make timely determination or provide written notice
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insurer with new information regarding internal appeal -- Time frame for insurer to render a decision based on new information -- Insurer's failure to make timely determination or provide written notice. (1) (a) If the covered person, authorized person, or provider has new clinic…
KRS § 304.17A-621 Independent External Review Program
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The Independent External Review Program is hereby established in the department. The program shall provide covered persons with a formal, independent review to address disagreements between the covered person and the covered person's insurer. This section and KRS 304.17A-623, 304…
KRS § 304.17A-623 External review of adverse benefit determination -- Who may request -- Criteria for review -- Fee -- Conditions under which covered person not entitled to review -- Resolution of disputes -- Confidentiality -- Expedited external review
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-- Criteria for review -- Fee -- Conditions under which covered person not entitled to review -- Resolution of disputes -- Confidentiality -- Expedited external review. (1) (a) Every insurer shall have an external review process to be utilized by the insurer or its designee, cons…
KRS § 304.17A-625 Factors to be considered by independent review entity conducting external review -- Basis for decision -- Insurer's responsibilities -- Contents, admissibility, and effect of decision -- Consequence of insurer's failure to provide coverage -- Liability -- Written complaints
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external review -- Basis for decision -- Insurer's responsibilities -- Contents, admissibility, and effect of decision -- Consequence of insurer's failure to provide coverage -- Liability -- Written complaints. (1) In making its decision, an independent review entity conducting t…
KRS § 304.17A-627 Certification as independent review entity -- Requirements and restrictions
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restrictions. (1) To be certified as an independent review entity under this chapter, an organization shall submit to the department an application on a form required by the department. The application shall include the following: (a) The name of each stockholder or owner of more…
KRS § 304.17A-629 Administrative regulations to implement provisions of KRS 304.17A-621, 304.17A-623, 304.17A-625, 304.17A-627, 304.17A-629, and 304.17A-631
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621, 304.17A-623, 304.17A-625, 304.17A-627, 304.17A-629, and 304.17A-631. The commissioner shall promulgate administrative regulations to implement the provisions of KRS 304.17A-621, 304.17A-623, 304.17A-625, 304.17A-627, 304.17A- 629, and 304.17A-631.
KRS § 304.17A-631 Time for insurers to comply with administrative regulations
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Insurers subject to the administrative regulations required under KRS 304.17A-629 shall have no less than ninety (90) days to comply with the provisions of the administrative regulations.
KRS § 304.17A-633 Commissioner to report to Interim Joint Committee on Banking and Insurance and to Governor -- Contents of report
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Insurance and to Governor -- Contents of report. The commissioner shall report every six (6) months to the Interim Joint Committee on Banking and Insurance, and to the Governor on the state of the Independent External Review Program. The report shall include a summary of the numb…
KRS § 304.17A-640 Definitions for KRS 304.17A-640 et seq
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For purposes of KRS 304.17A-640, 304.17A-641, 304.17A-643, 304.17A-645, and 304.17A-647, "emergency medical condition" means: (1) A medical condition manifesting itself by acute symptoms of sufficient severity, including severe pain, that a prudent layperson would reasonably have…
KRS § 304.17A-641 Treatment of a stabilized covered person with an emergency medical condition in a nonparticipating hospital's emergency room
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condition in a nonparticipating hospital's emergency room. (1) Where a covered person with an emergency medical condition has been stabilized, as required by the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA), 42 U.S.C. sec. 300bb, in the emergency department of a…
KRS § 304.17A-643 Treatment of covered person under special circumstances
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(1) "Special circumstances" includes a circumstance in which a covered person has a disability, a congenital condition, a life-threatening illness, or is past the twenty- fourth week of pregnancy where disruption of the covered person's continuity of care could cause medical harm…
KRS § 304.17A-645 Covered person's access to participating nonprimary care physician specialist
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specialist. An insurer shall not, under its health benefit plan prohibit a primary care physician from authorizing a covered person's referral to a participating nonprimary care physician specialist. A primary care physician treating a covered person who has a chronic, disabling,…
KRS § 304.17A-647 Covered person's access to participating obstetrician or gynecologist -- Authorization for annual pap smear without referral
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- Authorization for annual pap smear without referral. (1) An insurer shall not, under its health benefit plan prohibit a primary care physician from authorizing a covered person's referral to a participating obstetrician or gynecologist. A primary care physician treating a cover…
KRS § 304.17A-649 Administrative regulations
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640 et seq. The commissioner shall promulgate administrative regulations necessary to implement the provisions of KRS 304.17A-640, 304.17A-641, 304.17A-643, 304.17A-645, and 304.17A-647.
KRS § 304.17A-655 Definitions for KRS 304.17A-655 to 304.17A-659. (Effective January 1, 2027)
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1, 2027) As used in KRS 304.17A-655 to 304.17A-659: (1) "Feeding or eating disorder": (a) Has the same meaning as in the most recent version of the Diagnostic and Statistical Manual of Mental Disorders; and (b) Includes: 1. Anorexia nervosa; 2. Bulimia nervosa; 3. Atypical anorex…
KRS § 304.17A-657 Coverage for feeding or eating disorders. (Effective January 1, 2027)
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A health plan shall provide coverage for the diagnosis and treatment of feeding or eating disorders.
KRS § 304.17A-659 Prohibited standards and permitted factors for coverage of feeding or eating disorder treatments. (Effective January 1, 2027)
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eating disorder treatments. (Effective January 1, 2027) An insurer that offers or provides coverage for the treatment of a diagnosed feeding or eating disorder under a health plan: (1) Shall not utilize any of the following standards as the sole reason for denying, limiting, or r…
KRS § 304.17A-660 Definitions for KRS 304.17A-660 to 304.17A-669
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As used in KRS 304.17A-660 to 304.17A-669, unless the context requires otherwise: (1) "Classification of benefits" means the classification of benefits set forth in 45 C.F.R. sec. 146.136(c)(2)(ii)(A); (2) "Mental health condition" means any condition or disorder that involves me…
KRS § 304.17A-661 Treatment of mental health conditions to be covered under terms or conditions that are no more restrictive than terms or conditions for treatment of physical health conditions -- Parity coverage for nonquantitative treatment limitations and medical necessity criteria
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conditions that are no more restrictive than terms or conditions for treatment of physical health conditions -- Parity coverage for nonquantitative treatment limitations and medical necessity criteria. (1) Notwithstanding any other provision of law: (a) 1. A health benefit plan i…
KRS § 304.17A-662 Reimbursement for health benefits delivered through psychiatric collaborative care model -- Exception
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collaborative care model -- Exception. (1) (a) As used in this section, "psychiatric collaborative care model": 1. Means the evidence-based, integrated behavioral health service delivery method described in 81 Fed. Reg. 80230 (November 15, 2016); and 2. Includes services that are…
KRS § 304.17A-665 Commissioner to report to Legislative Research Commission on impact of health insurance costs under KRS 304.17A-660 to 304.17A-669
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impact of health insurance costs under KRS 304.17A-660 to 304.17A-669. Sixty (60) days prior to the regular session of the General Assembly in 2002, and sixty (60) days prior to each subsequent even-numbered-year regular session of the General Assembly, the commissioner shall sub…
KRS § 304.17A-669 KRS 304.17A-660 to 304.17A-669 not to be construed as mandating coverage for mental health conditions -- Exemption from KRS 304.17A-660 to 304.17A-669
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coverage for mental health conditions -- Exemption from KRS 304.17A-660 to 304.17A-669. (1) Nothing in KRS 304.17A-660 to 304.17A-669 shall be construed as mandating coverage for mental health conditions. (2) A group health benefit plan covering fewer than fifty-one (51) employee…
KRS § 304.17A-700 Definitions for KRS 304.17A-700 to 304.17A-730 and KRS 205.593, 304.14-135, and 304.99-123
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304.14-135, and 304.99-123. As used in KRS 304.17A-700 to 304.17A-730 and KRS 205.593, 304.14-135, and 304.99-123: (1) "Adjudicate" means an insurer pays, contests, or denies a clean claim; (2) "Claims payment time frame" means the time period prescribed under KRS 304.17A-702 fol…
KRS § 304.17A-702 Claims payment time frames -- Duties of insurer
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(1) Except for claims involving organ transplants, each insurer shall reimburse a provider for a clean claim or send a written or an electronic notice denying or contesting the claim within thirty (30) calendar days from the date that the claim is received by the insurer or any e…
KRS § 304.17A-704 Insurer's acknowledgment of receipt of claim -- Inaccurate or insufficient claim information -- Claim status information
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insufficient claim information -- Claim status information. (1) (a) Within forty-eight (48) hours of receiving an original or corrected claim submitted electronically, an insurer, its agent, or designee shall acknowledge the date of receipt of the claim by an electronic transmiss…
KRS § 304.17A-705 Electronic claims submission
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(1) As used in this section, "insurer" has the same meaning as in KRS 304.17A-005. (2) Any contract between an insurer and its pharmacy benefits administrator that requires claims to be submitted electronically shall require that payment is to be made electronically to the partic…
KRS § 304.17A-706 Contested claims -- Delay of payment -- Conditions -- Procedure
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(1) An insurer may contest a clean claim only in the following instances: (a) The insurer has reasonable documented grounds to believe that the clean claim involves a preexisting condition, coordination of benefits within the meaning of KRS 304.18-085, or that another insurer is …
KRS § 304.17A-708 Resolution of payment errors -- Retroactive denial of claims -- Conditions
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Conditions. (1) An insurer shall not require a provider to appeal errors in payment where the insurer has not paid the claim according to the contracted rate. Miscalculations in payments made by the insurer shall be corrected and paid within thirty (30) calendar days upon the ins…
KRS § 304.17A-710 Disclosure of claims payment information to provider
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(1) In contracts with providers or in the provider manual or other document that sets forth the procedures for filing claims, an insurer shall disclose to providers: (a) The mailing or electronic address where claims should be sent for processing; (b) The phone number a provider …
KRS § 304.17A-712 Claim refunds and overpayments
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(1) Except as provided in subsection (2) of this section, if an insurer determines that payment was made for services rendered to an individual who was not eligible for coverage or that payment was made for services not covered by a covered person's health benefit plan, the insur…
KRS § 304.17A-714 Collection of claim overpayments -- Dispute resolution
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(1) Except for overpayments which are a result of an error in the payment rate or method, an insurer that determines that a provider was overpaid shall, within twenty-four (24) months from the date that the insurer paid the claim, provide written or electronic notice to the provi…
KRS § 304.17A-716 Prohibition against denial or reduction of payment for covered health benefit -- Conditions
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benefit -- Conditions. (1) No insurer or any other person providing or administering a health benefit plan shall deny or reduce payment for a service, procedure, treatment, drug, or device covered under the covered person's health benefit plan if: (a) The covered person's provide…
KRS § 304.17A-718 Disclosure of claims payment information to covered person
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(1) Beginning on January 1, 2001, upon issuance, delivery, or renewal of a health benefit plan in Kentucky, an insurer shall: (a) Clearly indicate on each covered person's identification card the mailing address where a claim for payment shall be sent; and (b) Issue new identific…
KRS § 304.17A-720 Administrative regulations for standardized health claim attachments -- Conformity with federal standards
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-- Conformity with federal standards. (1) In order to improve the efficiency and effectiveness of the health care system through administrative simplification of billing requirements, the commissioner shall prescribe, through the promulgation of administrative regulations, standa…
KRS § 304.17A-722 Administrative regulations on claims payment practices
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(1) No later than ninety (90) days following July 15, 2002, the department shall promulgate administrative regulations requiring all insurers to report information on a calendar quarter basis on prompt payment of claims to providers, as defined in KRS 304.17A-700, that shall be l…
KRS § 304.17A-724 Applicability of KRS 304.17A-700 to 304.17A-730 and KRS 205.593, 304.14-135, and 304.99-123
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304.14-135, and 304.99-123. KRS 304.17A-700 to 304.17A-730 and KRS 205.593, 304.14-135, and 304.99-123 apply to any entity an insurer contracts with to perform claims processing functions.
KRS § 304.17A-726 Exclusive application of KRS 304.17A-700 to 304.17A-730 and KRS 205.593, 304.14-135, and 304.99-123 to claims incurred and contracts made after July 14, 2000
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205.593, 304.14-135, and 304.99-123 to claims incurred and contracts made after July 14, 2000. Upon enactment, all health care claims incurred after July 14, 2000, and contractual agreements between insurers and providers regarding the payment of health care claims entered into a…
KRS § 304.17A-728 Contract disclosures of discounted fees -- Violation is unfair claims settlement practice
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settlement practice. (1) A provision identifying the products and markets applicable to any discount as provided in the contract shall be required of all contracts with a: (a) Provider or an organization of providers; or (b) Preferred provider organization that has a network of p…
KRS § 304.17A-730 Payment of interest for failing to pay, denying, or settling a clean claim as required
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claim as required. (1) An insurer that fails to pay, deny, or settle a clean claim in accordance with KRS 304.17A-700 to 304.17A-730 and KRS 205.593, 304.14-135, and 304.99-123 shall pay interest according to the following schedule on the amount of the claim that remains unpaid: …
KRS § 304.17A-732 Annual reports on providers prescribing medication for addiction treatment
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treatment. (1) As used in this section: (a) "Kentucky Board of Nursing" means the board established in KRS 314.121; and (b) "State Board of Medical Licensure" means the board established in KRS 311.530. (2) For all claims made during the preceding plan year, an insurer shall annu…
KRS § 304.17A-740 Definitions for KRS 304.17A-740 to 304.17A-743
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(1) As used in KRS 304.17A-740 to 304.17A-743, unless the context otherwise requires: (a) "Administrator" has the meaning provided in KRS 304.9-051; (b) "Auditing entity" means an insurer or an administrator that conducts or arranges for the performance of an audit of a pharmacy'…