806 KAR 17:480. Uniform evaluation and

reevaluation of providers.

 

      RELATES TO: KRS 205.560(12), 216B.155(2),

304.17A-005, 304.17A-500, 304.17A-545, 304.17A-575, 304.17A-576

      STATUTORY AUTHORITY: KRS 304.2-110(1),

304.17A-545(5)

      NECESSITY, FUNCTION, AND CONFORMITY: KRS

304.2-110(1) authorizes the executive director to promulgate reasonable

administrative regulations necessary for, or as an aid to, the effectuation of

any provision of the Kentucky Insurance Code as defined in KRS 304.1-010. EO

2008-507, effective June 16, 2008, established the Department of Insurance and

the Commissioner of Insurance as the head of the department. KRS 304.17A-545(5)

requires the executive director to promulgate administrative regulations to

establish a uniform application form and guidelines for the evaluation and

reevaluation of health care providers, including psychologists, who will be on

a managed care plan’s list of participating providers. This administrative

regulation establishes the uniform application form and guidelines for

evaluation and reevaluation of a health care provider, including a psychologist.

 

      Section 1. Definitions. (1) "Applicant"

is defined by KRS 304.17A-575(1).

      (2)"Commissioner" means the

Commissioner of Insurance.

      (3) "Evaluation" or

"credentialing" means:

      (a) A process for collecting and

verifying professional qualifications of a health care provider;

      (b) An assessment of a health care provider's

professional competence and conduct; and

      (c) A process to be completed before a

health care provider may participate in a provider network of an insurer on an

initial or ongoing basis.

      (4) "Form KAPER-1" means the uniform

application for credentialing or recredentialing of a health care provider pursuant

to KRS 304.17A-545(5).

      (5) "Health care provider" or

"provider" means a:

      (a) Health care provider pursuant to KRS

304.17A-005(23); or

      (b) Psychologist licensed under KRS Chapter

319.

      (6) "Insurer" is defined by KRS

304.17A-005(27).

      (7) "Managed care plan" is

defined by KRS 304.17A-500(9).

      (8) "Participating health care

provider" means a participating health care provider pursuant to KRS

304.17A-500(10), including a psychologist licensed under KRS Chapter 319.

      (9) "Provider network" is

defined by KRS 304.17A-005(35).

      (10) "Reevaluation" or

"recredentialing" means:

      (a) A process for collecting and

reverifying professional qualifications of a participating health care

provider; and

      (b) An assessment of a participating

health care provider’s professional competence and conduct.

 

      Section 2. Guidelines for an Insurer. (1)

Except as established in subsection

(3)(b) of this section,

an insurer which offers a managed care plan and performs credentialing or recredentialing

activities shall use Form KAPER-1, Part A to credential or recredential a

health care provider who desires participation in its provider network.

      (2) Pursuant to subsection (1) of this

section, an insurer shall:

      (a) Have a mechanism for making available

and accepting from a health care provider a handwritten or electronically

submitted Form KAPER-1, Part A for:

      1. Initial credentialing; and

      2. Recredentialing;

      (b) Within thirty (30) days of receipt of

a Form KAPER-1, Part A, electronically or in writing:

      1. Notify the health care provider of

receipt of the Form KAPER-1 and, if applicable, of any omitted or questionable

information included on the form;

      2. Offer assistance to the provider, if requested;

and

      (c)1. Within sixty (60) days of receipt

of a Form KAPER-1, Part A,

provide an

electronic or written notification regarding the status of credentialing to the

health care provider; and

      2. Extend the time period identified in

section 2(2)(c)1, due to extenuating circumstances if:

      a. Additional time is required by the

insurer to consider information submitted on the Form KAPER-1, Part A; and

      b. The health care provider is informed

of the need for more time, including information relating to the extenuating

circumstance, which caused the delay;

      (d) Provide electronic or written

notification as established in paragraph (c) of this subsection every thirty

(30) days after the initial notification until a final determination regarding

credential has been issued to the health care provider;

      (e) Not require:

      1. Information on the Form KAPER-1, Part

A, which is not relevant to the scope of practice, health care setting, or

service of the health care provider; and

      2. Routine recredentialing of a health

care provider more frequently than three (3) years from the previous

credentialing date; and

      (f) Upon making a final determination

regarding credentialing of an applicant in accordance with KRS 304.17A-576(1),

provide notification of the determination to the applicant.

      (3) An insurer may use:

      (a) Form KAPER-1, Part A to credential or

recredential an individual in its provider network other than a health care provider;

and

      (b) The provider credentialing

application form of the Council for Affordable Quality Healthcare as identified

in the introduction of the Form KAPER-1, Part A, in lieu of the Form KAPER-1,

Part A.

 

      Section 3. Incorporation by Reference.

(1) The "Kentucky Application for Provider Evaluation and

Reevaluation", Form KAPER-1 (4/2009), is incorporated by reference.

      (2) This material may be inspected,

copied, or obtained, subject to applicable copyright law, at the Department of

Insurance, 215 West Main Street, Frankfort, Kentucky 40601, Monday through Friday,

8 a.m. to 4:30 p.m. This material is also available on the Department of Insurance

Web site at: http://insurance.ky.gov. (32 Ky.R. 1028; Am. 1265; 1399;

3-3-2006; 33 Ky.R. 1726; 3028; 3193; eff. 5-4-2007; 35 Ky.R.1607; 2081; 2742;

eff. 7-6-2009.)