Form HIPMC-UR-2 "Annual Utilization Review (Ur) Report Form" - Kentucky

What Is Form HIPMC-UR-2?

This is a legal form that was released by the Kentucky Department of Insurance - a government authority operating within Kentucky. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on September 1, 2020;
  • The latest edition provided by the Kentucky Department of Insurance;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form HIPMC-UR-2 by clicking the link below or browse more documents and templates provided by the Kentucky Department of Insurance.

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Download Form HIPMC-UR-2 "Annual Utilization Review (Ur) Report Form" - Kentucky

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Company Name: ________________________________ Reporting Period: ___________ UR Registration #: _____________
Kentucky Department of Insurance
Division of Health, Life Insurance and Managed Care
Annual Utilization Review (UR) Report Form
Please check the appropriate entity:  Insurer  PRA-ERISA Self-Funded  PRA-Self-Funded Non-ERISA  Limited Health Service Organization (LHSO) or Self-Funded LHSO
Utilization Review
Total Number of UR
Number of UR Requests
Number of UR
Number of Internal
Number of Decisions
Requests
1
Approved
2
Requests Denied
2
Appeals
Reversed on Internal Appeal
1. Inpatient/Residential Services
2. Outpatient Services
3. Durable Medical Equipment
4. Prescription Drugs – Non Specialty
5. Prescription Drugs – Specialty
6. All other services
Totals:
Coverage Denial Determinations (if applicable)
3
Total Number of Coverage Denials
Total Number of Coverage Denials Reversed on Internal Appeal
Included in Utilization
Included in Timeframe
Review Grid
Compliance Grid
Timeframe Compliance
4
Report Item
Number
NOT
6. Total urgent preservice/prospective requests (including hospital admissions or outpatient surgery
processed in 72 hours or less
NOT
7. Total non-urgent preservice/prospective requests
processed in 15 calendar days or less
NOT
8. Total inpatient concurrent reviews
processed in 24 hours or less (includes emergency admissions where the covered person remains hospitalized
when request is made).
NOT
9. Total retrospective reviews
processed in 30 calendar days or less.
Total:
The UR Requests Approved and the UR Requests Denied should equal the Total UR Requests Received.
1
2
If a request is partially approved and denied; only record the case in the Denied column, not both.
3
The only coverage denials recorded in this grid should be true coverage denials as defined in KRS 304.17A-617(1)
HIPMC-UR-2
09/2020
Company Name: ________________________________ Reporting Period: ___________ UR Registration #: _____________
Kentucky Department of Insurance
Division of Health, Life Insurance and Managed Care
Annual Utilization Review (UR) Report Form
Please check the appropriate entity:  Insurer  PRA-ERISA Self-Funded  PRA-Self-Funded Non-ERISA  Limited Health Service Organization (LHSO) or Self-Funded LHSO
Utilization Review
Total Number of UR
Number of UR Requests
Number of UR
Number of Internal
Number of Decisions
Requests
1
Approved
2
Requests Denied
2
Appeals
Reversed on Internal Appeal
1. Inpatient/Residential Services
2. Outpatient Services
3. Durable Medical Equipment
4. Prescription Drugs – Non Specialty
5. Prescription Drugs – Specialty
6. All other services
Totals:
Coverage Denial Determinations (if applicable)
3
Total Number of Coverage Denials
Total Number of Coverage Denials Reversed on Internal Appeal
Included in Utilization
Included in Timeframe
Review Grid
Compliance Grid
Timeframe Compliance
4
Report Item
Number
NOT
6. Total urgent preservice/prospective requests (including hospital admissions or outpatient surgery
processed in 72 hours or less
NOT
7. Total non-urgent preservice/prospective requests
processed in 15 calendar days or less
NOT
8. Total inpatient concurrent reviews
processed in 24 hours or less (includes emergency admissions where the covered person remains hospitalized
when request is made).
NOT
9. Total retrospective reviews
processed in 30 calendar days or less.
Total:
The UR Requests Approved and the UR Requests Denied should equal the Total UR Requests Received.
1
2
If a request is partially approved and denied; only record the case in the Denied column, not both.
3
The only coverage denials recorded in this grid should be true coverage denials as defined in KRS 304.17A-617(1)
HIPMC-UR-2
09/2020
4
Any incidents of timeframe non-compliance must be explained in the memorandum required by number 10 of the instructions including why they occurred & the corrective action plan the UR
agent will take to prevent non-compliance in the future.
HIPMC-UR-2
09/2020
Annual Utilization Review (UR) Report (HIPMC-UR-2) Instructions
The Department is providing the information below to help complete the Annual Utilization Review Report.
1.
The report is due no later than March 31st of each year pursuant to 806 KAR 17:280 Section 9.
2.
Complete the report utilizing the interactive PDF form available from the Department’s website at http://insurance.ky.gov/
under Forms & Documents.
3.
Complete the report in the registered name of the Utilization Review Agent (see name as printed on UR Certificate issued
by the Department). If an entity provides UR services for multiple clients, report the accumulated totals into one report under the
registered agent’s registration number. Do not submit multiple reports for non-registered entities.
4.
Enter the appropriate reporting period as 01/01## to 12/31/## or as 20##.
5.
Enter the Utilization Review Registration Number, which is located on the UR Registration Certificate the Department issues
to each entity upon their approval to perform UR services.
6.
Click the appropriate checkbox for the type of entity the report is being submitted. The Department expects to see a
separate report for each type of entity if the registered entity performs multiple types of entities. Example: Company performs UR
services as a PRA for an Insurer and as a PRA for Self-Funded Non-ERISA plans, one report is to be submitted for the insurers reviews
and a separate one for the Self-funded non-ERISA plans reviews.
7.
In the Utilization Review table, enter all appropriate information. See the items below to clarify the data the Department is
requesting in this table.
a.
Do not record UR requests in multiple fields. (i.e. DME being recorded in both DME and Outpatient Services). Only record
each UR request in one of the six (6) listed categories.
b.
The All Other Services category should capture all requests that do not fit within the other five (5) categories.
c.
Every request must be recorded, not just an “overall” number (i.e. Hospital stays with multiple requests for extension of
days). In this case, each request for extension would be a new request due to timeframe compliance.
d.
The UR Requests Approved and the UR Requests Denied must equal the Total Number of UR Requests.
e.
If a request is partially approved or denied, only record that request it in the denied column, not both.
8.
In the Coverage Denial Determination table only, record the actual coverage denials that meet the definition of “Coverage
Denial” in KRS 304.17A-617(1). Also, check the appropriate column for whether the numbers reported in this section were included
in the Utilization Review grid or the Timeframe Compliance grid.
9.
In the Timeframe Compliance table, record only the cases that did not meet the specified timeframes. See the items below
to clarify the data the Department is requesting in this table.
a.
Item # 1 includes all pre-service or prospective urgent requests including any hospital admissions or outpatient surgeries.
b.
Item # 2 includes all non-urgent pre-service or prospective requests.
c.
Item # 3 includes all concurrent reviews including reviews of emergency admissions where the person is still hospitalized. If
multiple requests for the same inpatient stay are made, they should be recorded individually not as an “Overall” number, due to
having to meet specified timeframes.
d.
Item # 4 includes all requests made retrospectively.
10.
A memorandum explaining any requests that were non-compliant with the specified timeframes and provide a corrective
action plan to ensure timeframe compliance in the future must accompany the report. The Department expects all requests to be
completed within their respective timeframes. The Department expects all cases to meet the specified timeframes. The
Department uses this information to determine whether a formal corrective action plan or a revocation of a UR Registration is
warranted pursuant to 806 KAR 17:280 Section 5.
HIPMC-UR-2
09/2020
11.
The Department requests the submission of the report and memorandum be via email at DOI.UtilizationReview@ky.gov.
HIPMC-UR-2
09/2020
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