Kentucky Administrative Regulations
Title 803 - LABOR CABINET
Chapter 25 - Department of Workers' Claims
Section 803 KAR 25:190 - Utilization review - Medical Bill Audit - Medical Director - Appeal of Utilization Review Decisions
Universal Citation: 803 KY Admin Regs Service 25:190
Current through Register Vol. 51, No. 3, September 1, 2024
RELATES TO: KRS Chapter 342
NECESSITY, FUNCTION, AND CONFORMITY: KRS 342.260 provides that the Commissioner of the Department of Workers' Claims shall promulgate administrative regulations necessary to carry on the work of the Department of Workers' Claims, and the commissioner may promulgate administrative regulations not inconsistent with the provisions of KRS Chapter 342. KRS 342.035(5) provides that the commissioner of the Department of Workers' Claims shall promulgate administrative regulations that require each insurance carrier, group self-insurer and individual self-insured employer to certify to the commissioner the program it has adopted to insure compliance with the medical fee schedule provisions of KRS 342.035(1) and (4). KRS 342.035(5) also requires the commissioner to promulgate administrative regulations governing medical provider utilization review activities conducted by an insurance carrier, group self-insurer or self-insured employer pursuant to KRS Chapter 342. KRS 342.035(6) allows the commissioner to promulgate regulations incorporating managed care or other concepts intended to reduce costs or to speed the delivery of payment of medical services to employees receiving medical and related benefits under KRS Chapter 342. This administrative regulation insures that insurance carriers, group self-insurers, and individual self-insured employers implement a utilization review and audit program and establishes a medical director to speed the delivery of payment of medical services to employees receiving medical and related benefits under this chapter. This administrative regulation does not abrogate the right, as provided in KRS 342.020, of an injured employee to choose his treating physician, or an employer to participate in a managed health care system.
Section 1. Definitions.
(1) "Business day" means any day except
Saturday, Sunday or any day which is a legal holiday.
(2) "Calendar day" means all days in a month,
including Saturday, Sunday and any day which is a legal holiday.
(3) "Carrier" is defined by
KRS
342.0011(6).
(4) "Commissioner" is defined by
KRS
342.0011(9).
(5) "Denial" means a determination by the
utilization reviewer that the medical treatment, proposed treatment, service,
or medication under review is not medically necessary or appropriate and,
therefore, payment is not recommended.
(6) "Department" is defined by
KRS
342.0011(8).
(7) "Medical bill audit" means the review of
medical bills for services which have been provided to assure compliance with
adopted fee schedules.
(8) "Medical
Director" means the Medical Director of the Department of Workers' Claims
appointed by the Secretary.
(9)
"Medically necessary" or "medical necessity" means healthcare services,
including medications, that a medical provider, exercising prudent clinical
judgment, would provide to a patient for the purpose of preventing, evaluating,
diagnosing or treating an illness, injury, disease or its symptoms, and that
are:
(a) In accordance with generally accepted
standards of medical practice;
(b)
Clinically appropriate, in terms of type, frequency, extent, site and duration;
and
(c) Considered effective for
the patient's illness, injury, or disease. .
(10) "Medical provider" means physicians and
surgeons, psychologists, optometrists, dentists, podiatrists, osteopathic and
chiropractic practitioners, physician assistants, and advanced practice
registered nurses, acting within the scope of their license .
(11) "Physician" is defined by
KRS
342.0011(32).
(12) "Preauthorization" means a process
whereby payment for a medical service or course of treatment is assured in
advance by a carrier.
(13)
"Secretary" means the Secretary of the Kentucky Labor Cabinet.
(14) "Utilization review" means a review of
the medical necessity and appropriateness of medical care and services for
purposes of recommending payments for a compensable injury or
disease.
(15) "Utilization review
and medical bill audit plan" means the written plan submitted to the
commissioner by each carrier describing the procedures governing utilization
review and medical bill audit activities.
(16) "Vendor" means a person or entity which
implements a utilization review and medical bill audit program for purposes of
offering those services to carriers.
Section 2. Implementation.
(1) The requirements established in Sections
3 through 9 of this administrative regulation shall apply to all utilization
reviews and medical bill audits conducted before June 1, 2022.
(2) The requirements established in Sections
10 through 18 of this administrative regulation shall apply to all utilization
reviews and medical bill audits conducted on or after June 1, 2022.
Section 3. Utilization Review and Medical Bill Audit Program.
(1) The
utilization review program shall assure that:
(a) A utilization reviewer is appropriately
qualified;
(b) Treatment rendered
to an injured worker is medically necessary and appropriate; and
(c) Necessary medical services are not
withheld or unreasonably delayed.
(2) The medical bill audit program shall
assure that:
(a) A statement or payment for
medical goods and services and charges for a deposition, report, or photocopy
complies with KRS Chapter 342 and 803 KAR Chapter 25;
(b) A medical bill auditor is appropriately
qualified; and
(c) A statement for
medical services is not disputed without reasonable grounds.
Section 4. Utilization Review and Medical Bill Audit Plan Approval.
(1) A carrier shall fully implement and
maintain a utilization review and medical bill audit program.
(2) A carrier shall provide to the
commissioner a written plan describing the utilization review and medical bill
audit program. The commissioner shall approve each utilization review and
medical bill audit plan which complies with the requirements of this
administrative regulation and KRS Chapter 342.
(3) A vendor shall submit to the commissioner
for approval a written plan describing the utilization review and medical bill
audit program. Upon approval, the vendor shall receive written notice from the
commissioner .
(4) A carrier who
contracts with an approved vendor for utilization review or medical bill audit
services shall notify the commissioner of the contractual arrangement. The
contractual arrangement may provide for separate utilization review and medical
bill audit vendors.
(5) A plan
shall be approved for a period of four (4) years.
(a) At least ninety (90) calendar days prior
to the expiration of the period of approval, a carrier or its approved vendor
shall apply for renewal of the approval.
(b) During the term of an approved plan, the
commissioner shall be notified as soon as practicable of a material change in
the approved plan or a change in the selection of a vendor.
Section 5. Utilization Review and Medical Bill Audit Written Plan Requirements. The written utilization review and medical bill audit plan submitted to the commissioner shall include the following elements:
(1) A
description of the process, policies, and procedures for making
decisions;
(2) A description of the
specific criteria utilized in the decision making process, including a
description of the specific medical guidelines used as the resource to confirm
the medical diagnosis and to provide consistent criteria and practice standards
against which care quality and related costs are measured;
(3) A description of the criteria by which
claims, medical services and medical bills shall be selected for
review;
(4) A description of the
qualifications of internal and consulting personnel who shall conduct
utilization review and medical bill audit and the manner in which the personnel
shall be involved in the review process;
(5) A description of the process to assure
that a treatment plan shall be obtained for review by qualified medical
personnel if a treatment plan is required by
803
KAR 25:096;
(6) A description of the process to assure
that a physician shall be designated by each injured employee as required under
803
KAR 25:096;
(7) A description of the process for
rendering and promptly notifying the medical provider and employee of the
initial utilization review decision;
(8) A description of the reconsideration
process within the structure of the utilization review and medical bill audit
program;
(9) An assurance that a
database shall be maintained, which shall:
(a)
Record:
1. Each instance of utilization
review;
2. Each instance of medical
bill audit;
3. The name of the
reviewer;
4. The extent of the
review;
5. The conclusions of the
reviewer; and
6. The action, if
any, taken as the result of the review;
(b) Be maintained for a period of at least
two (2) years; and
(c) Be subject
to audit by the commissioner , or his agent, pursuant to
KRS
342.035(5)(b);
(10) An assurance that a toll free
line shall be provided for an employee or medical provider to contact the
utilization reviewer. The reviewer or a representative of the reviewer shall be
reasonably accessible to an interested party at least five (5) days per week,
forty (40) hours per week during normal business hours;
(11) A description of the policies and
procedures that shall be implemented to protect the confidentiality of patient
information; and
(12) An assurance
that medical treatment guidelines adopted by the commissioner pursuant to
KRS
342.035(8)(a) shall be
incorporated in the plan as the standard for, utilization review medical
decision making.
Section 6. Claim Selection Criteria.
(1)
Unless the carrier, in good faith, denies the claim as noncompensable, medical
services reasonably related to the claim shall be subject to utilization review
if:
(a) A medical provider requests
preauthorization of a medical treatment or procedure;
(b) Notification of a surgical procedure or
resident placement pursuant to an
803
KAR 25:096 treatment plan is received;
(c) The total medical costs cumulatively
exceed $3,000;
(d) The total lost
work days cumulatively exceed thirty (30) days; or
(e) An arbitrator or administrative law judge
orders a review.
(2) If
applicable, utilization review shall commence when the carrier has notice that
a claims selection criteria has been met.
(a)
The following requirements shall apply if preauthorization has been requested:
1. The initial utilization review decision
shall be communicated to the medical provider and employee within two (2)
business days of the initiation of the utilization review process, unless
additional information is required. If additional information is required,
tender of a single request shall be made within two (2) additional business
days.
2. The requested information
shall be submitted by the medical provider within ten (10) business
days.
3. The initial utilization
review decision shall be rendered within two (2) business days following
receipt of the requested information.
(b) The following requirements shall apply if
retrospective utilization review occurs:
1.
The initial utilization review decision shall be communicated to the medical
provider and employee within ten (10) calendar days of the initiation of the
utilization review process, unless additional information is required. If
additional information is required, tender of a single request shall be made
within two (2) additional business days.
2. The requested information shall be
submitted by the medical provider within ten (10) business days.
3. The initial utilization review decision
shall be rendered within two (2) business days following receipt of the
requested information.
(3) A medical provider may request an
expedited utilization review determination for proposed medical treatment or
services, the lack of which could reasonably be expected to lead to serious
physical or mental disability or death. The expedited utilization review
determination shall be provided within twenty-four (24) hours following a
request for expedited review.
(4)
Initiation of utilization review shall toll the thirty (30) day period for
challenging or paying medical expenses pursuant to
KRS
342.020(1). The thirty (30)
day period shall commence on the date of the final utilization review
decision.
(5) Each medical bill
audit shall be initiated within seven (7) calendar days of receipt to assure:
(a) Compliance with applicable fee schedules,
in accordance with 803 KAR Chapter 25;
(b) Accuracy; and
(c) That a physician has been designated in
accordance with
803
KAR 25:096.
(6) A medical bill audit shall not toll the
thirty (30) day period for challenging or paying medical expenses pursuant to
KRS
342.020(1).
Section 7. Utilization Review and Medical Bill Audit Personnel Qualifications.
(1) Utilization review personnel shall have
education, training, and experience necessary for evaluating the clinical
issues and services under review. The following professionals shall issue an
initial utilization review approval:
(a) A
physician;
(b) A registered
nurse;
(c) A licensed practical
nurse;
(d) A medical records
technician; or
(e) Other personnel
whose training and experience qualify them to issue decisions on medical
necessity or appropriateness.
(2) Only a physician may issue an initial
utilization review denial. A physician shall supervise utilization review
personnel in making utilization review recommendations. Personnel shall hold
the license required by the jurisdiction in which they are employed.
(3) Personnel conducting a medical bill audit
shall have the education, training or experience necessary for evaluating
medical bills and statements.
Section 8. Written Notice of Denial.
(1)
Following initial review, a written notice of denial shall:
(a) Be issued to both the medical provider
and the employee in a timely manner but no more than ten (10) calendar days
from the initiation of the utilization review process;
(b) Be clearly entitled "UTILIZATION REVIEW -
NOTICE OF DENIAL"; and
(c) Contain:
1. A statement of the medical reasons for
denial;
2. The name, state of
licensure and medical license number of the reviewer; and
3. An explanation of utilization review
reconsideration rights.
(2) Payment for medical services shall not be
denied on the basis of lack of information absent documentation of a good faith
effort to obtain the necessary information.
Section 9. Reconsideration.
(1) A reconsideration process to appeal an
initial decision shall be provided within the structure of utilization review.
(a) A request for reconsideration of the
initial utilization review decision shall be made by an aggrieved party within
fourteen (14) calendar days of receipt of a written notice of denial.
(b) Reconsideration of the initial
utilization review decision shall be conducted by a different reviewer of at
least the same qualifications as the initial reviewer.
(c) A written reconsideration decision shall
be rendered within ten (10) calendar days of receipt of a request for
reconsideration. The written decision shall be clearly entitled "UTILIZATION
REVIEW - RECONSIDERATION DECISION". If the reconsideration decision is made by
an appropriate specialist or subspecialist, the written decision shall further
be entitled "FINAL UTILIZATION REVIEW DECISION".
(d) Those portions of the medical record that
are relevant to the reconsideration, if authorized by the patient and in
accordance with state or federal law, shall be considered and providers shall
be given the opportunity to present additional information.
(2)
(a) If a utilization review denial is upheld
upon reconsideration and a board eligible or certified physician in the
appropriate specialty or subspecialty area, or a chiropractor qualified
pursuant to
KRS
312.200(3) and
201
KAR 21:095, has not previously reviewed the matter, an
aggrieved party may request further review by:
1. A board eligible or certified physician in
the appropriate specialty or subspecialty; or
2. A chiropractor qualified pursuant to
KRS
312.200(3) and
201
KAR 21:095.
(b) A written decision shall be rendered
within ten (10) calendar days of the request for specialty reconsideration. The
specialty decision shall be clearly entitled "FINAL UTILIZATION REVIEW
DECISION".
(3) A
reconsideration process to appeal an initial decision shall be provided within
the structure of medical bill audit.
(a) A
request for reconsideration of the medical bill audit decision shall be made by
an aggrieved party within fourteen (14) calendar days of receipt of that
decision.
(b) Reconsideration shall
be conducted by a different reviewer of at least the same qualifications as the
initial reviewer.
(c) A written
decision shall be rendered within ten (10) calendar days of receipt of a
request for reconsideration. The written decision shall be clearly entitled
"MEDICAL BILL AUDIT RECONSIDERATION DECISION".
(d) A request for reconsideration of the
medical bill audit decision shall not toll the thirty (30) day period for
challenging or paying medical expenses pursuant to
KRS
342.020(1).
Section 10. Utilization Review and Medical Bill Audit Program.
(1) The
utilization review program shall assure that:
(a) A utilization reviewer is appropriately
qualified;
(b) Treatment rendered
to an injured worker is medically necessary and appropriate; and
(c) Necessary medical services are not
withheld or unreasonably delayed.
(2) The medical bill audit program shall
assure that:
(a) A statement or payment for
medical goods and services and charges for a deposition, report, or photocopy
comply with KRS Chapter 342 and 803 KAR Chapter 25;
(b) A medical bill auditor is appropriately
qualified; and
(c) A statement for
medical services is not disputed without reasonable grounds.
Section 11. Utilization Review and Medical Bill Audit Plan Approval.
(1) A carrier shall fully implement and
maintain a utilization review and medical bill audit program.
(2) A carrier shall provide to the
commissioner a written plan describing the utilization review and medical bill
audit program. The commissioner shall approve each utilization review and
medical bill audit plan which complies with the requirements of this
administrative regulation and KRS Chapter 342.
(3) A vendor shall submit to the commissioner
for approval a written plan describing the utilization review and medical bill
audit program. Upon approval, the vendor shall receive written notice from the
commissioner.
(4) A carrier who
contracts with an approved vendor for utilization review or medical bill audit
services shall notify the commissioner of the contractual arrangement. The
contractual arrangement may provide for separate utilization review and medical
bill audit vendors.
(5) A plan
shall be approved for a period of four (4) years.
(a) At least ninety (90) calendar days prior
to the expiration of the period of approval, a carrier or its approved vendor
shall apply for renewal of the approval.
(b) During the term of an approved plan, the
commissioner shall be notified as soon as practicable of a material change in
the approved plan or a change in the selection of a vendor.
(6) A carrier, who contracts with
an approved vendor for utilization review services, shall provide annually to
the commissioner summaries of the number of utilization reviews, waivers per
KRS
342.035(5)(c), utilization
review approvals for treatment, utilization review denials for treatment and
appeals to the medical director. These annual reports of the approved vendor
shall be filed with the Department by August 1 for the preceding fiscal year
ending June 30.
Section 12. Utilization Review and Medical Bill Audit Written Plan Requirements. The written utilization review and medical bill audit plan submitted to the commissioner shall include the following elements:
(1) A description of the process, policies
and procedures for making decisions ;
(2) A description of the specific criteria
utilized in the decision making process, including a description of the
specific medical guidelines used as the resource to confirm the medical
diagnosis and to provide consistent criteria and practice standards against
which care quality and related costs are measured;
(3) A description of the criteria by which
claims, medical services and medical bills shall be selected for
review;
(4) A description of the:
(a) Qualifications of internal and consulting
personnel who shall conduct utilization review and medical bill audit;
and
(b) The manner in which the
personnel shall be involved in the review process;
(5) A description of the process to assure
that a treatment plan shall be obtained for review by qualified medical
personnel if a treatment plan is required by
803
KAR 25:096;
(6) A description of the process to assure
that a physician shall be designated by each injured employee as required under
803
KAR 25:096;
(7) A description of the process for
rendering and promptly notifying the medical provider and employee of the
initial utilization review decision;
(8) A description of the reconsideration
process within the structure of the utilization review and medical bill audit
program;
(9) An assurance that a
database shall be maintained, which shall:
(a)
Record:
1. Each instance of utilization
review;
2. Each instance of medical
bill audit;
3. The name of the
reviewer;
4. The extent of the
review;
5. The conclusions of the
reviewer; and
6. The action, if
any, taken as the result of the review;
(b) Be maintained for a period of at least
two (2) years; and
(c) Be subject
to audit by the commissioner, or his agent, pursuant to
KRS
342.035(5)(b);
(10) An assurance that a toll free
line shall be provided for an employee or medical provider to contact the
utilization reviewer. The reviewer or a representative of the reviewer shall be
reasonably accessible to an interested party at least five (5) days per week,
forty (40) hours per week during normal business hours;
(11) A description of the policies and
procedures that shall be implemented to protect the confidentiality of patient
information; and
(12) An assurance
that medical treatment guidelines adopted by the commissioner pursuant to
KRS
342.035(8)(a) shall be
incorporated in the plan as the standard for, utilization review medical
decision making.
Section 13. Claim Selection Criteria and Process.
(1) Unless the medical payment obligor, in
good faith, denies the claim as noncompensable or waives utilization review
pursuant to
KRS
342.035(5)(c), medical
services reasonably related or asserted to be related to the claim shall be
subject to utilization review if:
(a) A
medical provider requests preauthorization of a medical treatment or
procedure;
(b) Notification of a
surgical procedure or resident placement pursuant to an
803
KAR 25:096 treatment plan is received;
(c) The total medical costs cumulatively
exceed $3,000; or
(d) The total
lost work days cumulatively exceed thirty (30) days.
(2) Utilization review shall commence when
the medical payment obligor has notice that a claims selection criteria has
been met. The medical payment obligor may waive utilization review pursuant to
KRS
342.035(5)(c) within two (2)
business days of the notice. Failure by the medical payment obligor to waive
and communicate its waiver to the employee and medical provider or initiate its
utilization review process within two (2) business days shall result in the
medical payment obligor paying for the subject medical services pursuant to the
appropriate fee schedules, in accordance with 803 KAR Chapter 25.
(a) The following requirements shall apply if
preauthorization has been requested and utilization review has not been waived:
1. The utilization review decision shall be
rendered and communicated to the medical provider and employee, and the
employee's attorney if represented, within two (2) business days of the
initiation of the utilization review process, unless additional information is
required. If additional information is required, a single request shall be made
within two (2) additional business days.
2. The requested information shall be
submitted by the medical provider within five (5) business days.
3. The utilization review decision shall be
rendered and communicated within two (2) business days following receipt of the
requested information.
(b) The following requirements shall apply if
retrospective utilization review occurs:
1.
The utilization review decision shall be rendered and communicated to the
medical provider and employee, and the employee's attorney if represented,
within five (5) business days of the initiation of the utilization review
process, unless additional information is required. If additional information
is required, a single request shall be made within two (2) additional business
days.
2. The requested information
shall be submitted by the medical provider within five (5) business
days.
3. The utilization review
decision shall be rendered and communicated within two (2) business days
following receipt of the requested information.
(3) A medical provider may request an
expedited utilization review determination for proposed medical treatment or
services, the lack of which could reasonably be expected to lead to serious
physical or mental disability or death. The expedited utilization review
determination shall be rendered and communicated within twenty-four (24) hours
following a request for expedited review.
(4) Initiation of utilization review shall
toll the thirty (30) day period for paying medical expenses pursuant to
KRS
342.020(4). The thirty (30)
day period for paying medical expenses shall commence on the date of the
utilization review decision.
(5)
Each medical bill audit shall be initiated within seven (7) calendar days of
receipt to assure:
(a) Compliance with
applicable fee schedules, in accordance with 803 KAR Chapter 25;
(b) Accuracy; and
(c) That a physician has been designated in
accordance with
803
KAR 25:096.
(6) A medical bill audit shall not toll the
thirty (30) day period for challenging or paying medical expenses pursuant to
KRS
342.020(4).
Section 14. Utilization Review and Medical Bill Audit Personnel Qualifications.
(1) Utilization review personnel shall have
education, training, and experience necessary for evaluating the clinical
issues and services under review. A physician, registered nurse, licensed
practical nurse, medical records technician or other personnel, who through
training and experience is qualified to issue decisions on medical necessity or
appropriateness, shall issue the initial utilization review approval.
(2) Only a physician may issue an initial
utilization review denial. A physician shall supervise utilization review
personnel in making utilization review recommendations. Personnel shall hold
the license required by the jurisdiction in which they are employed.
(3) Personnel conducting a medical bill audit
shall have the education, training or experience necessary for evaluating
medical bills and statements.
Section 15. Written Notice of Denial.
(1)
Following utilization review, a written notice of denial shall:
(a) Be clearly entitled "UTILIZATION REVIEW -
NOTICE OF DENIAL"; and
(b) Contain:
1. A statement of the medical reasons for
denial;
2. The name, state of
licensure, and medical license number of the reviewer; and
3. An explanation of utilization appeal
rights with instructions on how to proceed with an appeal.
(2) The Department shall develop
and provide a form on its website that a medical payment obligor may use to
comply with Section 15 (1) above.
(3) A copy of the written notice of denial
along with the mailing address, telephone number, and, if known, the email
address of the employee, the employee's attorney if represented, and medical
provider whose treatment, recommended treatment, or prescribed medication is
being denied shall be sent by electronic mail to the medical director on the
same day that the notice of denial is rendered and communicated to that medical
provider and employee. The medical director shall then immediately notify the
employee, the employee's attorney if represented, and that medical provider of
the actions required to appeal the utilization review denial at no cost to the
employee.
(4) Payment for medical
services shall not be denied on the basis of lack of information absent
documentation of a good faith effort to obtain the necessary
information.
Section 16. Medical Director.
(1) Within the department
there shall be a medical director. The medical director shall be a licensed
physician in good standing with the Kentucky Board of Medical
Licensure.
(2) The Secretary shall
appoint the medical director, upon consultation with the Commissioner to a term
of four (4) years. A medical director may serve more than one (1) term of four
(4) years.
(3) If a vacancy occurs
during a four (4) year term, the secretary shall appoint a licensed physician
in good standing with the Kentucky Board of Medical Licensure as medical
director for the unexpired term. Nothing in this administrative regulation
shall prevent the Secretary from appointing a licensed physician in good
standing with the Kentucky Board of Medical Licensure to fill an unexpired term
and to serve a subsequent term.
(4)
After consultation with the Commissioner, the Secretary may remove the medical
director for good cause, the grounds for which shall be expressed in
writing.
(5) The medical director
shall:
(a) Process appeals of utilization
review decisions pursuant to this administrative regulation; and
(b) At least annually, review and advise the
Commissioner and the Secretary on the effectiveness of the Medical Fee Schedule
for Physicians, the Treatment Guidelines and the Pharmaceutical Formulary in
reducing costs and speeding the delivery of medical services to employees
receiving medical benefits under KRS Chapter 342.
(6) If the treatment is outside of the
medical director's certification or specialty, the medical director may seek
the assistance of other physicians with the appropriate certification or
specialty to assist or perform any tasks outlined within this administrative
regulation; the other physicians shall not be the physician whose treatment or
recommended treatment is under review or the physicians who issued or upheld
the utilization review denial.
(7)
The medical director shall chair a Workers' Compensation Medical Advisory
Committee to provide advice on issues related to the medical treatment of
injured workers. The medical director may request the committee to advise on
the medical aspects of the Department's various programs in advancing the goal
of ensuring that all injured employees receive superior quality and cost
efficient treatment to facilitate recovery from injury and a swift, safe return
to the workforce.
(a) In addition to the
medical director serving as chair, the commissioner shall serve on the Workers'
Compensation Medical Advisory Committee and may appoint the following to the
Workers' Compensation Medical Advisory Committee:
1. Deputy commissioner; and
2. A representative for:
a. Employers;
b. Employees;
c. Labor unions;
d. Insurance;
e. Self-insured employers;
f. Occupational medicine;
g. Chiropractic;
h. Orthopedics;
i. Neurosurgery;,
j. Psychiatry ;
k. Pain management rehabilitation;
l. Pain management;
m. Emergency medicine;
n. Hospitals, ; and
o. Pharmacies .
(b) No less than annually, the
Workers' Compensation Medical Advisory Committee shall provide the commissioner
and Secretary with a report concerning the activity, effectiveness and impact
of the medical director and the utilization review programs on the delivery of
payment of medical services to injured employees.
Section 17. Appeals of Utilization Review Decisions.
(1) Upon receipt of a
written notice of denial of treatment subject to utilization review, the
employee or medical provider whose treatment, recommended treatment, or
prescribed medication, is being denied may appeal the utilization review
decision to the medical director.
(2) The employee or medical provider whose
treatment, recommended treatment, or prescribed medication is being denied
shall have thirty (30) calendar days from receipt of the written notice of
denial to appeal the utilization review decision to the medical director. The
medical director may extend the time to appeal upon request and for
cause.
(3) Failure to appeal to the
medical director shall result in the utilization review decision having
preclusive effect as to the reasonableness and necessity of the
treatment.
(4) An appeal to the
medical director shall toll the thirty (30) day period for paying medical
expenses pursuant to
KRS
342.020(4). The thirty (30)
day period to pay the approved medical expenses shall commence on the date of
the medical director's written determination or the date on which the parties
reach agreement regarding disputed treatment.
(5) The Department shall charge a fee of $200
for each appeal submitted to the medical director. The fee shall be paid by the
medical payment obligor no later than twenty-one (21) calendar days following
the date of the appeal to the medical director. Failure to pay the fee shall
constitute a failure to complete a necessary step in the administrative review
process. This failure shall be construed as an admission by the employer that
the denial was in error, and the medical director shall find accordingly.
Failure to pay the fee may also result in assessment of a civil penalty
pursuant to
KRS
342.990(7)(e).
(6)
(a) The
appeal shall be dismissed if, within five (5) calendar days of the appeal to
the medical director, the medical payment obligor provides notice of dismissal
to the:
1. Medical director;
2. Medical provider whose treatment,
recommended treatment, or prescribed medication is being denied; and
3. Employee.
(b) With this dismissal, the medical payment
obligor shall authorize the payment of the questioned services pursuant to the
appropriate fee schedule, in accordance with 803 KAR Chapter 25. If the
dismissal occurs, a fee as required by this administrative regulation shall not
be due, or if paid, the fee shall be refunded to the medical payment
obligor.
(7) Upon
receipt of an appeal request by an employee or medical provider whose treatment
or recommended treatment is being denied:
(a)
The medical director shall conduct the utilization review appeal in keeping
with the treatment guidelines and pharmaceutical formulary created or adopted
by the commissioner.
(b) The
medical director shall consider the opinion of the medical provider whose
treatment, recommended treatment, or prescribed medication is being
denied.
(c) The medical director
may contact the medical provider whose treatment, recommended treatment, or
prescribed medication is being denied for the purpose of obtaining any
necessary missing information. Necessary information shall be considered
missing until the medical director has obtained:
1. All of the records reviewed by the
physician that issued the utilization review denial; and
2. All medical treatment records from the
date of the injury or for the two year period preceding the date of the
utilization review, whichever is shorter, for the injury or occupational
disease giving rise to the treatment, recommended treatment, or prescribed
medication for which the utilization review denial was issued.
(d) Within seven (7) calendar days
from receipt of the appeal, the medical director shall set a date on which all
relevant information shall be due to the medical director.
(e) The medical director shall determine the
medical necessity of the treatment, recommended treatment, or prescribed
medication within fourteen (14) calendar days after receipt of all necessary
information by the medical director.
(f) Upon determination that any or all of the
treatment, recommended treatment, or prescribed medication is reasonable and
necessary, the medical director shall plainly state the reasons for each
approval in a written determination.
(g) Upon determination that any or all of the
treatment, recommended treatment, or prescribed medication is not reasonable
and necessary, the medical director shall plainly state the reasons for each
denial in a written determination.
(h) No later than two (2) days after the
medical director has made a determination, the medical director shall transmit
the written determination to the medical provider whose treatment, recommended
treatment, or prescribed medication, is being denied; the employee; the
employee's attorney if represented; the employer; and the medical payment
obligor by facsimile, electronic mail, or the United States Postal Service
.
(i) If the medical director
determines that there was no reasonable basis upon which to deny the treatment,
recommended treatment, or prescribed medication, or that the medical payment
obligor failed to follow the required utilization review procedure, then the
medical director shall request the commissioner or the administrative law judge
to impose the appropriate penalties, fines, or sanctions on the medical payment
obligor by directing that the employee's or physician's costs of the appeal,
including reasonable attorney's fees, be paid by the medical payment
obligor.
(j) If at any time during
the appeal with the medical director, the medical payment obligor raises work
relatedness, causation or non-compensability issues, the parties shall be
advised by the medical director that resolution of these issues requires a
filing of an application for adjustment of claim or Form 112, Medical Dispute,
whichever is appropriate. The medical director, however, shall continue with
the appeal and issue a written determination of the reasonableness and
necessity of the proposed medical treatment consistent with this
regulation.
(8) A
determination by the medical director of the reasonableness and necessity of
the treatment, recommended treatment, or prescribed medication shall remain
effective for six (6) months from the date of the written determination of the
medical director, unless a change in condition is shown by objective medical
findings.
(9) If the medical
director's determination is to approve the medical treatment, the medical
payment obligor shall pay for the treatment, recommended treatment, or
prescribed medication within the thirty (30) day time period set forth in
KRS
342.020(4) unless a Form
112, Medical Dispute, is timely filed.
(10) If a party disagrees with the medical
director's written determination, the aggrieved party may file a Form 112,
Medical Dispute, and proceed in accordance with
803 KAR
25:012.
(11) The filing of a Form 112, Medical
Dispute, shall toll the thirty (30) day period for paying medical expenses
pursuant to
KRS
342.020(4) until such time
as the reasonableness and necessity of the proposed medical treatment is
decided by an administrative law judge.
(12) Failure to file a Form 112, Medical
Dispute, within thirty (30) calendar days shall result in the written
determination of the medical director having preclusive effect as to the
reasonableness and necessity of the treatment that is the subject of the
medical director's determination.
Section 18. Reconsideration and Appeals of Medical Bill Audit Decisions. A reconsideration process to appeal an initial decision shall be provided within the structure of medical bill audit.
(1) A request for reconsideration of the
medical bill audit decision shall be made by an ag-grieved party within
fourteen (14) calendar days of receipt of that decision.
(2) Reconsideration shall be conducted by a
different reviewer of at least the same qualifications as the initial
reviewer.
(3) A written decision
shall be rendered within ten (10) calendar days of receipt of a request for
reconsideration. The written decision shall be clearly entitled "MEDICAL BILL
AUDIT-RECONSIDERATION DECISION".
(4) A request for reconsideration of the
medical bill audit decision shall not toll the thirty (30) day period for
challenging or paying medical expenses pursuant to
KRS
342.020(1).
Section 19. This administrative regulation was found deficient by the Administrative Regulation Review Subcommittee on November 9, 2021.
STATUTORY AUTHORITY: KRS 342.035(5) and (6), 342.260
Disclaimer: These regulations may not be the most recent version. Kentucky may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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