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 Kentucky Administrative Regulations (Last Updated: August 1, 2016)
 TITLE 806. PUBLIC PROTECTION CABINET - DEPARTMENT OF INSURANCE
 Chapter 17. Health Insurance Contracts

806 KAR 17:005. Health Insurance forms and reports  

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  •       Section 1. Forms and Reports. (1) Form HIPMC-RF-25, Basic Health Benefit Plan Summary Sheet-Form and Rate Filings, shall be filed by an insurer with a form or rate for a basic health benefit plan.

          (2) Form HIPMC-BHP-1, Basic Health Benefit Plan Annual Report, shall be filed annually by an insurer offering a basic health benefit plan.

          (3) Form HIPMC-R32, Health Benefit Plan Rate Filing Information Form, shall be filed with a rate for a health benefit plan.

          (4) Form HIPMC-F1, Face Sheet and Verification Form, shall be filed as the coversheet of a rate or form filing for a health benefit plan.

          (5) An Income and Expense Worksheet shall be filed with a rate for a health benefit plan.

          (6) Form HIPMC-R33, Health Benefit Plan Regions, which includes eight (8) identified health benefit plan regions in Kentucky, may be filed for a geographic region factor adjustment in a rate for a health benefit plan.

          (7) Form HIPMC-R34, Certification Form, shall be filed with a rate for a health benefit plan for an individual, association, or small group.

          (8) Form HIPMC-IRE-1, Application for Certification of an Independent Review Entity, shall be filed by an independent review entity applying for certification to perform external reviews in Kentucky.

          (9) Form HIPMC-IRE-2, Assignment of Independent Review Entity Form, shall be filed by an insurer if an external review is assigned to an independent review entity.

          (10) Form HIPMC-IRE-3, External Review Decision Notification Form, shall be used by an independent review entity to notify the Department of Insurance of an external review decision.

          (11) Form HIPMC-IRE-4, Annual Independent Review Entity Report Form, shall be filed by an independent review entity annually with the Department of Insurance.

          (12) Form HIPMC-IRE-5, Approval of an External Review Fee in excess of $800, shall be used by the Department of Insurance to approve excess fees of an independent review entity in unusual or complicated circumstances.

          (13) Form HIPMC-IRE-6, External Review Information Face Sheet, shall be used by an insurer to provide information and documentation relating to an external review to an independent review entity.

          (14) Form HIPMC-UR-1, Utilization Review Registration Application, shall be filed by an insurer or private review agent applying for registration to perform utilization review in Kentucky.

          (15) Form HIPMC-UR-2, Annual Utilization Review Report Form, shall be filed by an insurer or private review agent annually to the Department of Insurance.

          (16) Form HIPMC-R1, Risk-sharing Arrangement Information Sheet, shall be filed by an insurer for each risk-sharing arrangement in force.

     

          Section 2. Incorporation by Reference. (1) The following material is incorporated by reference:

          (a) "HIPMC-RF-25, Basic Health Benefit Plan Summary Sheet-Form and Rate Filings", 07/2008;

          (b) "HIPMC-BHP-1, Basic Health Benefit Plan Annual Report", 07/2008;

          (c) "HIPMC-R32, Health Benefit Plan Rate Filing Information Form", 07/2008;

          (d) "HIPMC-F1, Face Sheet and Verification Form", 07/2008;

          (e) "Income and Expense Worksheet", 1998;

          (f) "HIPMC-R33, Health Benefit Plan Regions", 12/00;

          (g) "HIPMC-R34, Certification Form", 07/2008;

          (h) "HIPMC-IRE-1, Application for Certification of an Independent Review Entity", 07/2008;

          (i) "HIPMC-IRE-2, Assignment of Independent Review Entity Form", 7/2008;

          (j) "HIPMC-IRE-3, External Review Decision Notification Form", 07/2008;

          (k) "HIPMC-IRE-4, Annual Independent Review Entity Report Form", 07/2008;

          (l) "HIPMC-IRE-5, Approval of an External Review Fee in excess of $800", 07/2008;

          (m) "HIPMC-IRE-6, External Review Information Face Sheet", 07/2008;

          (n) "HIPMC-UR-1, Utilization Review Registration Application", 07/2008;

          (o) "HIPMC-UR-2, Annual Utilization Review Report Form", 07/2008; and

          (p) "HIPMC-R1, Risk-sharing Arrangement Information Sheet", 07/00.

          (2) This material may be inspected, copied, or obtained, subject to applicable copyright law, at the Kentucky Department of Insurance, 215 West Main Street, Frankfort, Kentucky 40601, Monday through Friday, 8 a.m. to 4:30 p.m.

          (3) Forms may also be obtained on the Department of Insurance Web site at http://insurance.ky.gov. (34 Ky.R. 1906; Am. 2095; eff. 4-4-08; 35 Ky.R. 652; 1189; eff. 12-5-2008.)

Notation

      RELATES TO: KRS 304.1-010, 304.4-010, 304.14-120, 304.14-190, 304.17A-095, 304.17A-096, 304.17A-600-304.17A-629

      STATUTORY AUTHORITY: KRS 304.2-110(1)

      NECESSITY, FUNCTION, AND CONFORMITY: KRS 304.2-110(1) authorizes the executive director of insurance to promulgate reasonable administrative rules and administrative regulations necessary for or as an aid to the effectuation of any provision of the Kentucky Insurance Code, as defined by KRS 304.1-010. EO 2008-507, effective June 16, 2008, established the Department of Insurance and the Commissioner of Insurance as head of the department. This administrative regulation establishes forms and reports to be submitted to the Department of Insurance by a health insurer or independent review entity.