# 806 KAR 17:005: 806 KAR 17:005. Health insurance forms and reports

> Kentucky · Regulations · In force

URL: https://www.frixlaw.com/law-library/statutes/STATE_KY_KAR_T806_C017_R005

## Section

- **Citation:** 806 KAR 17:005
- **Heading:** 806 KAR 17:005. Health insurance forms and reports
- **Jurisdiction:** Kentucky
- **Kind:** Regulations
- **Status:** In force
- **Text as of:** August 14, 2026
- **Source:** Compiled text
- **Location:** Kentucky Administrative Regulations / Title 806 (Public Protection Cabinet - Department of Insurance) / Chapter 017 / 806 KAR 17:005

## Text

Section 1. Forms and Reports. (1) Form HIPMC-RF-25, Basic Health Benefit Plan Summary Sheet-Form and Rate Filings, shall be filed by an insurer with a form or rate for a basic health benefit plan. (2) Form HIPMC-BHP-1, Basic Health Benefit Plan Annual Report, shall be filed annually by an insurer offering a basic health benefit plan. (3) Form HIPMC-R32, Health Benefit Plan Rate Filing Information Form, shall be filed with a rate for a health benefit plan. (4) Form HIPMC-F1, Face Sheet and Verification Form, shall be filed as the coversheet of a rate or form filing for a health benefit plan. (5) An Income and Expense Worksheet shall be filed with a rate for a health benefit plan. (6) Form HIPMC-R33, Health Benefit Plan Regions, which includes eight (8) identified health benefit plan regions in Kentucky, may be filed for a geographic region factor adjustment in a rate for a health benefit plan. (7) Form HIPMC-R34, Certification Form, shall be filed with a rate for a health benefit plan for an individual, association, or small group. (8) Form HIPMC-IRE-1, Application for Certification of an Independent Review Entity, shall be filed by an independent review entity applying for certification to perform external reviews in Kentucky. (9) Form HIPMC-IRE-2, Assignment of Independent Review Entity Form, shall be filed by an insurer if an external review is assigned to an independent review entity. (10) Form HIPMC-IRE-3, External Review Decision Notification Form, shall be used by an independent review entity to notify the Department of Insurance of an external review decision. (11) Form HIPMC-IRE-4, Annual Independent Review Entity Report Form, shall be filed by an independent review entity annually with the Department of Insurance. (12) Form HIPMC-IRE-5, Approval of an External Review Fee in excess of $800, shall be used by the Department of Insurance to approve excess fees of an independent review entity in unusual or complicated circumstances
xternal review decision. (11) Form HIPMC-IRE-4, Annual Independent Review Entity Report Form, shall be filed by an independent review entity annually with the Department of Insurance. (12) Form HIPMC-IRE-5, Approval of an External Review Fee in excess of $800, shall be used by the Department of Insurance to approve excess fees of an independent review entity in unusual or complicated circumstances. (13) Form HIPMC-IRE-6, External Review Information Face Sheet, shall be used by an insurer to provide information and documentation relating to an external review to an independent review entity. (14) Form HIPMC-UR-1, Utilization Review Registration Application, shall be filed by an insurer or private review agent applying for registration to perform utilization review in Kentucky. (15) Form HIPMC-UR-2, Annual Utilization Review Report Form, shall be filed by an insurer or private review agent annually to the Department of Insurance. (16) Form HIPMC-R1, Risk-sharing Arrangement Information Sheet, shall be filed by an insurer for each risk-sharing arrangement in force. Section 2. Incorporation by Reference. (1) The following material is incorporated by reference: (a) "HIPMC-RF-25, Basic Health Benefit Plan Summary Sheet-Form and Rate Filings", 07/2008; (b) "HIPMC-BHP-1, Basic Health Benefit Plan Annual Report", 07/2008; (c) "HIPMC-R32, Health Benefit Plan Rate Filing Information Form", 07/2008; (d) "HIPMC-F1, Face Sheet and Verification Form", 07/2008; (e) "Income and Expense Worksheet", 1998; (f) "HIPMC-R33, Health Benefit Plan Regions", 12/00; (g) "HIPMC-R34, Certification Form", 07/2008; (h) "HIPMC-IRE-1, Application for Certification of an Independent Review Entity", 07/2008; (i) "HIPMC-IRE-2, Assignment of Independent Review Entity Form", 7/2008; (j) "HIPMC-IRE-3, External Review Decision Notification Form", 07/2008; (k) "HIPMC-IRE-4, Annual Independent Review Entity Report Form", 07/2008; (l) "HIPMC-IRE-5, Approval of an External Review Fee in excess of $800", 07/2008; (m) "HIPMC-IRE-6, External Review Information
tification of an Independent Review Entity", 07/2008; (i) "HIPMC-IRE-2, Assignment of Independent Review Entity Form", 7/2008; (j) "HIPMC-IRE-3, External Review Decision Notification Form", 07/2008; (k) "HIPMC-IRE-4, Annual Independent Review Entity Report Form", 07/2008; (l) "HIPMC-IRE-5, Approval of an External Review Fee in excess of $800", 07/2008; (m) "HIPMC-IRE-6, External Review Information Face Sheet", 07/2008; (n) "HIPMC-UR-1, Utilization Review Registration Application", 07/2008; (o) "HIPMC-UR-2, Annual Utilization Review Report Form", 07/2008; and (p) "HIPMC-R1, Risk-sharing Arrangement Information Sheet", 07/00. (2) This material may be inspected, copied, or obtained, subject to applicable copyright law, at the Kentucky Department of Insurance, 215 West Main Street, Frankfort, Kentucky 40601, Monday through Friday, 8 a.m. to 4:30 p.m. (3) Forms may also be obtained on the Department of Insurance Web site at http://insurance.ky.gov.

## Nearby sections

- [806 KAR 17:005 806 KAR 17:005. Health insurance forms and reports](https://www.frixlaw.com/law-library/statutes/STATE_KY_KAR_T806_C017_R005.md)
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- [806 KAR 17:070 806 KAR 17:070. Filing procedures for health insurance rates](https://www.frixlaw.com/law-library/statutes/STATE_KY_KAR_T806_C017_R070.md)
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- [806 KAR 17:150 806 KAR 17:150. Health benefit plan rate filing requirements](https://www.frixlaw.com/law-library/statutes/STATE_KY_KAR_T806_C017_R150.md)
- [806 KAR 17:160 806 KAR 17:160. Creditable coverage for health insurance](https://www.frixlaw.com/law-library/statutes/STATE_KY_KAR_T806_C017_R160.md)
- [806 KAR 17:180 806 KAR 17:180. Standard health benefit plan](https://www.frixlaw.com/law-library/statutes/STATE_KY_KAR_T806_C017_R180.md)
- [806 KAR 17:190 806 KAR 17:190. Guaranteed Acceptance Program requirements](https://www.frixlaw.com/law-library/statutes/STATE_KY_KAR_T806_C017_R190.md)
- [806 KAR 17:230 806 KAR 17:230. Requirements regarding medical director's signature on health care benefit denials](https://www.frixlaw.com/law-library/statutes/STATE_KY_KAR_T806_C017_R230.md)

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Source: Frix Law Library, https://www.frixlaw.com/law-library/statutes/STATE_KY_KAR_T806_C017_R005. Check the current official text before relying on it. Not legal advice.