Kentucky's external review sits in KRS 304.17A. A request must be filed within four months, and the insurer is the party that opens the case: it requests the review from a Department-assigned certified independent review entity through the Department's eServices system. For an expedited review the entity must determine the case within 24 hours of receiving all required information from the insurer, extendable by a further 24 hours only if the covered person and the insurer agree. The instructions for starting the process must appear in the internal appeal decision letter that upheld the denial.
The 24-hour expedited clock
For an expedited external review the independent review entity must reach a determination within 24 hours from receipt of all information required from the insurer. An extension of up to 24 more hours is possible, but only where the covered person and the insurer or its designee agree to it.
The clock starts on the insurer's file, not your request
Four months, and the insurer opens the case
The filing window is four months under KRS 304.17A-600(1) and 304.17A-617(1). Kentucky then routes the mechanics through the insurer rather than the patient: an insurer must request the external review from a Department-assigned, certified independent review entity via the Department's eServices system. The covered person triggers it; the insurer files it.
The instructions have to be in the denial letter
Kentucky requires the internal appeal decision letter that upholds an adverse determination to carry the instructions for initiating external review — including how to request and complete any necessary forms, such as a medical-records release or a written authorisation of representation. If those instructions are missing from the letter, that omission is itself worth raising with the Department.
Plan type still governs
How to start one
- 1
Finish the internal appeal
External review follows the insurer's internal appeal of the adverse determination.
- 2
Read the upheld-denial letter for the instructions
Kentucky requires that letter to explain how to initiate external review and which forms are needed.
- 3
Complete the release and authorisation
A medical-records release, and a written authorisation of representation where someone is acting for the patient, are the forms most often required.
- 4
Ask the Department if it stalls
The Health Policy Utilization Review Branch handles questions on the independent external review programme at (502) 564-6088.
Who conducts the review
The reviewing bodies are independent review entities certified by the Department, which maintains the list and makes the assignment. The insurer does not choose which entity receives the case; it submits the request into the Department's system and the assignment comes back.
Who the reviewers are, and where the list lives
Kentucky certifies the bodies that perform external review and publishes the roster, so the entity deciding a case is drawn from a known, regulated pool rather than an arrangement between the plan and a vendor of its choosing. The Department's Health Policy Utilization Review Branch administers the programme and maintains the certification, and its independent-review-entity guides set out what those entities must do.
- Independent review entities are certified by the Department, which publishes the current list.
- Assignment comes from the Department, not from the insurer's preference.
- The Department's review guides govern how those entities handle the file.
- Questions on the programme go to the Health Policy Utilization Review Branch on (502) 564-6088.
For Kentucky practices
The 24-hour expedited determination is worth building a habit around. Where a delay would genuinely jeopardise the patient, the expedited track in Kentucky resolves in a day rather than most of a week — but only once the insurer's file reaches the reviewer. A short written request to the plan to transmit immediately, sent the same day the expedited review is invoked, is the difference between the statutory clock running and waiting for it to start.
The letter has to tell the provider about specialty review
Kentucky requires the specialty match at the point of decision. KRS 304.17A-607 provides that only the appropriate specialty or subspecialty provider may make a utilization review decision.
It also requires the denial letter to say so. The adverse determination notice must inform the covered person, an authorized person or the provider of the right to ask that a board-certified or board-eligible physician in the appropriate specialty or subspecialty conduct the review. The same section sets the clocks: urgent pre-authorization decisions within 24 hours of all necessary information, non-urgent within five days.
Frequently asked
How long do I have to request external review in Kentucky?
How fast is an expedited review decided?
Who actually files the request?
How do I know what forms are needed?
Who chooses the reviewing entity?
Does Kentucky's process cover an ERISA plan?
Primary sources: KRS 304.17A-623 — External review of adverse determination; Kentucky DOI — Independent Review Entity Review Guide; Kentucky DOI — Appealing a denial from your health benefit plan; 45 CFR 147.136 (internal claims, appeals & external review); HealthCare.gov — external review process. General information, not legal or medical advice — confirm against the governing rule for the plan type.
When the appeal has to be written, and cited
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