304.17A-600 Definitions for KRS 304.17A-600 to 304.17A-633. (Effective until January 1, 2020) As used in KRS 304.17A-600 to 304.17A-633: (1) (a) "Adverse determination" means a determination by an insurer or its designee that the health care services furnished or proposed to be furnished to a covered person are: (2) (3) (4) (5) (6) 1. Not medically necessary, as determined by the insurer, or its designee or experimental or investigational, as determined by the insurer, or its designee; and 2. Benefit coverage is therefore denied, reduced, or terminated. (b) "Adverse determination" does not mean a determination by an insurer or its designee that the health care services furnished or proposed to be furnished to a covered person are specifically limited or excluded in the covered person's health benefit plan; "Authorized person" means a parent, guardian, or other person authorized to act on behalf of a covered person with respect to health care decisions; "Concurrent review" means utilization review conducted during a covered person's course of treatment or hospital stay; "Covered person" means a person covered under a health benefit plan; "External review" means a review that is conducted by an independent review entity which meets specified criteria as established in KRS 304.17A-623, 304.17A-625, and 304.17A-627; "Health benefit plan" means the document evidencing and setting forth the terms and conditions of coverage of any hospital or medical expense policy or certificate; nonprofit hospital, medical-surgical, and health service corporation contract or certificate; provider sponsored integrated health delivery network policy or certificate; a self-insured policy or certificate or a policy or certificate provided by a multiple employer welfare arrangement, to the extent permitted by ERISA; health maintenance organization contract; or any health benefit plan that affects the rights of a Kentucky insured and bears a reasonable relation to Kentucky, whether delivered or issued for delivery in Kentucky, and does not include policies covering only accident, credit, dental, disability income, fixed indemnity medical expense reimbursement policy, long-term care, Medicare supplement, specified disease, vision care, coverage issued as a supplement to liability insurance, insurance arising out of a workers' compensation or similar law, automobile medical-payment insurance, insurance under which benefits are payable with or without regard to fault and that is statutorily required to be contained in any liability insurance policy or equivalent self-insurance, student health insurance offered by a Kentucky- licensed insurer under written contract with a university or college whose students it proposes to insure, medical expense reimbursement policies specifically designed to fill gaps in primary coverage, coinsurance, or deductibles and provided under a separate policy, certificate, or contract, or coverage supplemental to the coverage provided under Chapter 55 of Title 10, United States Code; or limited health service (7) (8) benefit plans; and for purposes of KRS 304.17A-600 to 304.17A-633 includes short-term coverage policies; "Independent review entity" means an individual or organization certified by the department to perform external reviews under KRS 304.17A-623, 304.17A-625, and 304.17A-627; "Insurer" means any of the following entities authorized to issue health benefit plans as defined in subsection (6) of this section: an insurance company, health maintenance organization; self-insurer or multiple employer welfare arrangement not exempt from state regulation by ERISA; provider-sponsored integrated health delivery network; self-insured employer-organized association; nonprofit hospital, medical-surgical, or health service corporation; or any other entity authorized to transact health insurance business in Kentucky; (9) "Internal appeals process" means a formal process, as set forth in KRS 304.17A- 617, established and maintained by the insurer, its designee, or agent whereby the covered person, an authorized person, or a provider may contest an adverse determination rendered by the insurer, its designee, or private review agent; (10) "Nationally recognized accreditation organization" means a private nonprofit entity that sets national utilization review and internal appeal standards and conducts review of insurers, agents, or independent review entities for the purpose of accreditation or certification. Nationally recognized accreditation organizations shall include the Accreditation Association for Ambulatory Health Care (AAAHC), the National Committee the American Accreditation Health Care Commission (URAC), the Joint Commission, or any other organization identified by the department; for Quality Assurance (NCQA), (11) "Private review agent" or "agent" means a person or entity performing utilization review that is either affiliated with, under contract with, or acting on behalf of any insurer or other person providing or administering health benefits to citizens of this Commonwealth. "Private review agent" or "agent" does not include an independent review entity which performs external review of adverse determinations; (12) "Prospective review" means utilization review that is conducted prior to a hospital admission or a course of treatment; (13) "Provider" shall have the same meaning as set forth in KRS 304.17A-005; (14) "Qualified personnel" means licensed physician, registered nurse, licensed practical nurse, medical records technician, or other licensed medical personnel who through training and experience shall render consistent decisions based on the review criteria; (15) "Registration" means an authorization issued by the department to an insurer or a private review agent to conduct utilization review; (16) "Retrospective review" means utilization review that is conducted after health care services have been provided to a covered person. "Retrospective review" does not include the review of a claim that is limited to an evaluation of reimbursement levels, or adjudication of payment; (17) (a) "Urgent care" means health care or treatment with respect to which the application of the time periods for making nonurgent determination: 1. Could seriously jeopardize the life or health of the covered person or the ability of the covered person to regain maximum function; or 2. In the opinion of a physician with knowledge of the covered person's medical condition, would subject the covered person to severe pain that cannot be adequately managed without the care or treatment that is the subject of the utilization review; and (b) "Urgent care" shall include all requests for hospitalization and outpatient surgery; (18) "Utilization review" means a review of the medical necessity and appropriateness of hospital resources and medical services given or proposed to be given to a covered person for purposes of determining the availability of payment. Areas of review include concurrent, prospective, and retrospective review; and (19) "Utilization review plan" means a description of the procedures governing utilization review activities performed by an insurer or a private review agent. Effective: June 29, 2017 History: Amended 2017 Ky. Acts ch. 80, sec. 56, effective June 29, 2017. -- Amended 2015 Ky. Acts ch. 9, sec. 7, effective June 24, 2015. -- Amended 2010 Ky. Acts ch. 24, sec. 1235, effective July 15, 2010. -- Amended 2004 Ky. Acts ch. 59, sec. 11, effective July 13, 2004. -- Amended 2002 Ky. Acts ch. 181, sec. 4, effective July 15, 2002. -- Created 2000 Ky. Acts ch. 262, sec. 1, effective July 14, 2000.