Section 304.17A-700 - Definitions for KRS 304.17A-700 to 304.17A-730 and KRS 205.593, 304.14-135, and 304.99-123As used in KRS 304.17A-700 to 304.17A-730 and KRS 205.593, 304.14-135, and 304.99-123:
(1) "Adjudicate" means an insurer pays, contests, or denies a clean claim;(2) "Claims payment time frame" means the time period prescribed under KRS 304.17A-702 following receipt of a clean claim from a provider at the address published by the insurer, whether it is the address of the insurer or a delegated claims processor, within which an insurer is required to pay, contest, or deny a health care claim;(3) "Clean claim" means a properly completed billing instrument, paper or electronic, including the required health claim attachments, submitted in the following applicable form: (a) A clean claim from an institutional provider shall consist of:1. The UB-92 data set or its successor submitted on the designated paper or electronic format as adopted by the NUBC;2. Entries stated as mandatory by the NUBC; and3. Any state-designated data requirements determined and approved by the Kentucky State Uniform Billing Committee and included in the UB-92 billing manual effective at the time of service.(b) A clean claim for dentists shall consist of the form and data set approved by the American Dental Association.(c) A clean claim for all other providers shall consist of the HCFA 1500 data set or its successor submitted on the designated paper or electronic format as adopted by the National Uniform Claims Committee.(d) A clean claim for pharmacists shall consist of a universal claim form and data set approved by the National Council on Prescription Drug Programs;(4) "Commissioner" means the commissioner of the Department of Insurance;(5) "Covered person" means a person on whose behalf an insurer offering a health benefit plan is obligated to pay benefits or provide services;(6) "Department" means the Department of Insurance;(7) "Electronic" or "electronically" means electronic mail, computerized files, communications, or transmittals by way of technology having electrical, digital, magnetic, wireless, optical, electromagnetic, or similar capabilities;(8) "Health benefit plan" has the same meaning as provided in KRS 304.17A-005;(9) "Health care provider" or "provider" means a provider licensed in Kentucky as defined in KRS 304.17A-005 and, for the purposes of KRS 304.17A-700 to 304.17A-730 and KRS 205.532, 205.593, 304.14-135, and 304.99-123 only, shall include physical therapists licensed under KRS Chapter 327, psychologists licensed under KRS Chapter 319, and social workers licensed under KRS Chapter 335. Nothing contained in KRS 304.17A-700 to 304.17A-730 and KRS 205.593, 304.14-135, and 304.99-123 shall be construed to include physical therapists, psychologists, and social workers as a health care provider or provider under KRS 304.17A-005;(10) "Health claim attachments" means medical information from a covered person's medical record required by the insurer containing medical information relating to the diagnosis, the treatment, or services rendered to the covered person and as may be required pursuant to KRS 304.17A-720;(11) "Institutional provider" means a health care facility licensed under KRS Chapter 216B;(12) "Insurer" has the same meaning provided in KRS 304.17A-005;(13) "Kentucky Uniform Billing Committee (KUBC)" means the committee of health care providers, governmental payors, and commercial insurers established as a local arm of NUBC to implement the bill requirements of the NUBC and to prescribe any additional billing requirements unique to Kentucky insurers;(14) "National Uniform Billing Committee (NUBC)" means the national committee of health care providers, governmental payors, and commercial insurers that develops the national uniform billing requirements for institutional providers as referenced in accordance with the Federal Health Insurance Portability and Accountability Act of 1996, 42 U.S.C. Chapter 6A, Subchapter XXV, secs. 300gg et seq.;(15) "Retrospective review" means utilization review that is conducted after health care services have been provided to a covered person; and(16) "Utilization review" has the same meaning as provided in KRS 304.17A-600.Amended by 2018 Ky. Acts ch. 106,§ 9, eff. 1/1/2019.Effective:7/15/2010
Amended 2010, Ky. Acts ch. 24, sec. 1248, effective7/15/2010. -- Amended 2004, Ky. Acts ch. 59, sec. 16, effective 7/13/2004. -- Amended 2002, Ky. Acts ch. 181, sec. 11, effective 7/15/2002. -- Created 2000, Ky. Acts ch. 436, sec. 1, effective 7/14/2000.