Kentucky Revised Statutes Title XXV. Business and Financial Institutions § 304.17A-600.Definitions for KRS 304.17A-600 to 304.17A-633

(2) “Authorized person” means a parent, guardian, or other person authorized to act on behalf of a covered person with respect to health care decisions;

(3) “Concurrent review” means utilization review conducted during a covered person's course of treatment or hospital stay;

(4) “Covered person” means a person covered under a health benefit plan;

(5) “External review” means a review that is conducted by an independent review entity which meets specified criteria as established in KRS 304.17A-623, 304.17A-625, and 304.17A-627;

(6) “Health benefit plan” has the same meaning as in KRS 304.17A-005, except that for purposes of KRS 304.17A-600 to 304.17A-633, the term includes short-term coverage policies;

(7) “Independent review entity” means an individual or organization certified by the department to perform external reviews under KRS 304.17A-623, 304.17A-625, and 304.17A-627;

(8) “Insurer” means any of the following entities authorized to issue health benefit plans as defined in subsection (6) of this section: an insurance company, health maintenance organization; self-insurer or multiple employer welfare arrangement not exempt from state regulation by ERISA; provider-sponsored integrated health delivery network; self-insured employer-organized association; nonprofit hospital, medical-surgical, or health service corporation; or any other entity authorized to transact health insurance business in Kentucky;

(9) “Internal appeals process” means a formal process, as set forth in KRS 304.17A-617, established and maintained by the insurer, its designee, or agent whereby the covered person, an authorized person, or a provider may contest an adverse determination rendered by the insurer, its designee, or private review agent;

(10) “Nationally recognized accreditation organization”:

(11) “Private review agent” or “agent”:

(12) “Prospective review” means a utilization review that is conducted prior to the provision of health care services. “Prospective review” also includes any insurer's or agent's requirement that a covered person or provider notify the insurer or agent prior to providing a health care service, including but not limited to prior authorization, step therapy protocol, preadmission review, pretreatment review, utilization, and case management;

(13) “Qualified personnel” means licensed physician, registered nurse, licensed practical nurse, medical records technician, or other licensed medical personnel who through training and experience shall render consistent decisions based on the review criteria;

(14) “Registration” means an authorization issued by the department to an insurer or a private review agent to conduct utilization review;

(15) “Retrospective review”:

(17) “Utilization review” means a review of the medical necessity and appropriateness of hospital resources and medical services given or proposed to be given to a covered person for purposes of determining the availability of payment. Areas of review include concurrent, prospective, and retrospective review; and

(18) “Utilization review plan” means a description of the procedures governing utilization review activities performed by an insurer or a private review agent.