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.
| 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 |
