806 KAR 17:230. Requirements regarding medical director's signature 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(18).

 

      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.

 

      Section 3. Appointment of Medical Director. (1) A managed care plan shall submit to the office a:

      (a) Completed form HIPMC-MD-1, incorporated by reference in this Administrative regulation; and

      (b) Biographical resume of each individual who shall serve as the medical director of the managed care plan.

      (2) A managed care plan shall furnish the office 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 in the event of the medical director’s absence and furnish the office 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 same sent to the provider.

      (2) Letters of denial requiring signature of the medical director of a managed care plan pursuant to KRS 304.17A-545(1)(d) 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) Electronic signature.

 

      Section 6. Incorporation by Reference. (1) Medical Director Report Form HIPMC-MD-1, (10/2000) is incorporated by reference.

      (2) This material may be inspected, copied, or obtained, subject to applicable copyright law, at the Kentucky Office of Insurance, 215 West Main Street, Frankfort, Kentucky 40601, Monday through Friday, 8 a.m. to 4:30 p.m. (27 Ky.R. 1694; Am. 2189; 2451; eff. 3-19-2001; TAm eff. 8-9-2007; TAm eff. 10-9-2008.)

Notation

      RELATES TO: KRS 304.17A-540, 304.17A-545

      STATUTORY AUTHORITY: KRS 304.2-110(1)

      NECESSITY, FUNCTION, AND CONFORMITY: KRS 304.2-110(1) provides that the Executive Director may promulgate reasonable rules and regulations necessary for or as an aid to the effectuation of any provision of the Kentucky Insurance Code. This administrative regulation establishes the procedure to be followed when a medical director’s signature is required on health care benefit denials.