Utilization Management Review
If you are experiencing problems with utilization management review, such as increased administrative burden and delayed patient access to care, here’s what you can do to help us address this issue:
- Share Information
Let us know when you experience issues related to a UM rollout. Please provide a detailed account of the concern but DO NOT include patient personal health information (PHI).
- Advocate for Your Patients
File a complaint with the Kentucky Department of Insurance on behalf of your patients. Providers may file a consumer complaint on behalf of their patients. You have the option of
- filing an online complaint or
- printing a complaint form to mail or fax.
- Advocate for Yourself
Kentucky’s Orange Envelope Law. According to KRS 304.17A 235 an insurer must give providers 90 days advance notice of a material change to a contract in an orange-colored envelope with the phrase "ATTENTION! CONTRACT AMENDMENT ENCLOSED!" Among other things, a material change includes changes to administrative procedures that may significantly increase the provider's administrative expense, and includes any changes to provider network requirements, or inclusion in any new or modified insurance products. If you feel an insurer has violated KRS 304.17A 235 you may file a complaint with the Kentucky Department of Insurance on behalf of your practice. Providers will use the consumer complaint form and in the box labeled “describe your complaint” indicate you feel that the orange envelope law (KRS 304.17A 235) has been violated and why. Please notify APTA-KY if you file an orange envelope law complaint.
Providers are encouraged to appeal all denials or inappropriate modifications of treatment. Provider appeal templates are available here.
- Other Ways to Advocate
If medically necessary care is delayed or access impeded, providers may facilitate patient reporting or submit their own complaints to the employer/human resource department, payer, and legislators. See below for template letters.
Acting in the best interest of the patient is an ongoing process that depends on close communication between APTA-KY and our members. Everything we get from you—any data as well as your individual accounts of impact—is used in advocacy efforts with the payer, UM vendor and other stakeholders including federal agencies and the state insurance commissioner.