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Kentucky
General Information and Internal Plan Review:
Kentucky categorizes health plan refusals for service as
either coverage denials or adverse determinations. A coverage
denial involves services, treatments, drugs, or devices that
the health plan claims are not covered by the health plan
contract. An adverse determination involves services, treatments,
drugs, or devices that the health plan claims are not medically
necessary or appropriate, or are experimental or investigational.
If you receive either a "notice of coverage denial" or
a "denial letter of adverse determination," you
are eligible to ask the health plan for an internal appeal
which will be completed within 30 days of the request (or
within 3 business days of the request if you are hospitalized
or a treating physician states that a review under the standard
time frame could jeopardize your health).
If you are not satisfied with the result of appealing a coverage denial,
you can write the Department of Insurance and request a coverage denial
review. If the coverage denial requires resolution of a medical issue,
the Department may require your health plan to allow you an external
review.
If you are not satisfied with the result of appealing a denial letter
of adverse determination, you can contact your health plan and request
an external review.
The External Review of Adverse Determination Process:
Whom to contact: |
Your health plan |
Who can appeal: |
You, your provider
(with consent and authorization), or your authorized
representative |
What you can appeal: |
Adverse determinations:
services, treatments, drugs, or devices that
the health plan claims are not medically necessary
or appropriate, or are experimental or investigational,
for services that would have cost you at least
$100 if you had no insurance. |
When you can appeal: |
After you exhaust
the health plan’s internal appeal process,
or if you and your health plan agree to waive
the internal appeal process, you must file
within 60 days after receipt of an adverse
determination. |
What to send: |
Written request,
medical records release, and written designation/authorization
of person or provider, if applicable. |
What you must pay: |
$25 filing fee
payable to the independent review entity (may
be refunded if the decision is in your favor,
or may be waived for financial hardship). |
What will happen: |
- Your health plan will determine whether
or not to grant an external review based
upon established criteria and arrange
the external review, if indicated.
- If you are not granted a review, you may
file a written complaint with the Department
of Insurance and the Department will
decide whether or not you will receive an external
review within 5 days.
- If you are granted an external review,
an independent review entity will be
assigned to your case.
- The independent review entity decides your
case.
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When you will get
a decision: |
Within 21 days
(unless you and your health plan agree to an
additional 14-day extension) |
In urgent situations: |
If you are in the
hospital or your treating physician states
that an external review under the 21-day time
frame could jeopardize your health, a determination
will be made in 24 hours (unless you and your
health plan agree to an additional 24-hour
extension). |
How to Get More Information:
Kentucky Department of Insurance, 800-595-6053 or 800-462-2081
(Hearing Impaired)
www.doi.state.ky.us
Information updated as of 8-30-2004
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