Montana Code 33-32-309. Expedited review of grievance involving adverse determination
33-32-309. Expedited review of grievance involving adverse determination. (1) A health insurance issuer shall establish written procedures for the expedited review of urgent care requests of grievances involving an adverse determination.
Terms Used In Montana Code 33-32-309
- Authorized representative: means :
(a)a person to whom a covered person has given express written consent to represent the covered person;
(b)a person authorized by law to provided substituted consent for a covered person; or
(c)a family member of the covered person, or the covered person's treating health care provider, only if the covered person is unable to provide consent. See Montana Code 33-32-102
- Concurrent review: means a utilization review conducted during a patient's stay or course of treatment in a facility, the office of a health care professional, or another inpatient or outpatient health care setting. See Montana Code 33-32-102
- Contract: A legal written agreement that becomes binding when signed.
- Covered person: means a policyholder, a certificate holder, a member, a subscriber, an enrollee, or another individual participating in a health plan. See Montana Code 33-32-102
- Emergency services: has the meaning provided in 33-36-103. See Montana Code 33-32-102
- Evidence: Information presented in testimony or in documents that is used to persuade the fact finder (judge or jury) to decide the case for one side or the other.
- External review: describes the set of procedures provided for in Title 33, chapter 32, part 4. See Montana Code 33-32-102
- Grievance: means a written complaint or an oral complaint if the complaint involves an urgent care request submitted by or on behalf of a covered person regarding:
(a)availability, delivery, or quality of health care services, including a complaint regarding an adverse determination made pursuant to utilization review;
(b)claims payment, handling, or reimbursement for health care services; or
(c)matters pertaining to the contractual relationship between a covered person and a health insurance issuer. See Montana Code 33-32-102
- Health insurance issuer: has the meaning provided in 33-22-140. See Montana Code 33-32-102
- Jurisdiction: (1) The legal authority of a court to hear and decide a case. Concurrent jurisdiction exists when two courts have simultaneous responsibility for the same case. (2) The geographic area over which the court has authority to decide cases.
- Medical necessity: means health care services that a health care provider exercising prudent clinical judgment would provide to a patient for the purpose of preventing, evaluating, diagnosing, treating, curing, or relieving a health condition, illness, injury, or disease or its symptoms and that are:
(a)in accordance with generally accepted standards of practice;
(b)clinically appropriate in terms of type, frequency, extent, site, and duration and are considered effective for the patient's illness, injury, or disease; and
(c)not primarily for the convenience of the patient or health care provider and not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of the patient's illness, injury, or disease. See Montana Code 33-32-102
- Person: means an individual, a corporation, a partnership, an association, a joint venture, a joint stock company, a trust, an unincorporated organization, or any similar entity or combination of entities in this subsection. See Montana Code 33-32-102
- Process: means a writ or summons issued in the course of judicial proceedings. See Montana Code 1-1-202
- provider: means a person, corporation, facility, or institution licensed by the state to provide, or otherwise lawfully providing, health care services, including but not limited to:
(a)a physician, physician assistant, advanced practice registered nurse, health care facility as defined in 50-5-101, osteopath, dentist, nurse, optometrist, chiropractor, podiatrist, physical therapist, psychologist, licensed social worker, speech pathologist, audiologist, licensed addiction counselor, or licensed professional counselor; and
(b)an officer, employee, or agent of a person described in subsection (18)(a) acting in the course and scope of employment. See Montana Code 33-32-102
- State: when applied to the different parts of the United States, includes the District of Columbia and the territories. See Montana Code 1-1-201
- Urgent care request: means a request for a health care service or course of treatment with respect to which the time periods for making a nonurgent care request determination could:
(i)seriously jeopardize the life or health of the covered person or the ability of the covered person to regain maximum function; or
(ii)subject the covered person, in the opinion of a health care provider with knowledge of the covered person's medical condition, to severe pain that cannot be adequately managed without the health care service or treatment that is the subject of the request. See Montana Code 33-32-102
- Writing: includes printing. See Montana Code 1-1-203
(2)A health insurance issuer shall provide an expedited review of a grievance involving an adverse determination with respect to a concurrent review of an urgent care request involving an admission, availability of care, continued stay, or health care service for a covered person who has received emergency services but has not been discharged from a facility. The procedures in subsection (1) must also specify the process for the concurrent review of urgent care requests under this subsection (2).
(3)The procedures under this section must provide that a covered person or, if applicable, the covered person’s authorized representative may request an expedited review orally, in writing, or electronically.
(4)On receipt of a request for an expedited review, a health insurance issuer shall appoint one or more physicians or health care professionals of the same licensure to review the adverse determination. An appointed physician or health care professional of the same licensure may not have been involved in making the initial adverse determination.
(5)In an expedited review, all necessary information, including the health insurance issuer’s decision, must be transmitted between the health insurance issuer and the covered person or, if applicable, the covered person’s authorized representative in the most expeditious method available, whether by telephone, facsimile, or other method.
(6)(a) The timeframe for making a decision under an expedited review and notification, as provided in subsection (8), must be as expeditious as the covered person’s medical condition requires but may take no more than 72 hours after the receipt of the request for the expedited review.
(b)If the expedited review is of a grievance involving an adverse determination with respect to a concurrent review urgent care request, the health insurance issuer shall continue the health care service or treatment without liability to the covered person until the covered person has been notified of the determination.
(7)For purposes of calculating the timeframe within which a decision is required to be made under subsection (6), the time period within which the decision must be made begins on the date the request is filed with the health insurance issuer in accordance with the health insurance issuer’s procedures for filing requests established under 33-32-307 without regard to whether all of the information necessary to make the determination accompanies the filing.
(8)A notification of a decision under this section must be in a manner calculated to be understood by the covered person or, if applicable, the covered person’s authorized representative and, if necessary, meet the requirements of subsection (9). The notification must include:
(a)the titles and qualifying credentials of each physician or health care professional of the same licensure participating in the expedited review process;
(b)information sufficient to identify the claim involved with respect to the grievance, including the date of service, the health care provider, and, if applicable, the claim amount;
(c)a statement describing the availability, upon request, of the diagnosis code and its corresponding meaning and the treatment code and its corresponding meaning. On receiving a request for a diagnosis or treatment code, the health insurance issuer shall provide the information as soon as practicable. A health insurance issuer may not consider a request for the diagnosis code and treatment information, in itself, to be a request to file a grievance for external review as outlined in Title 33, chapter 32, part 4.
(d)a statement from the physicians or health care professionals of the same licensure participating in the review of their understanding of the covered person’s grievance;
(e)a description in clear terms of the decision of the physicians or health care professionals of the same licensure and the contract basis or medical rationale in sufficient detail for the covered person to respond further to the health insurance issuer’s position;
(f)a reference to the evidence or documentation used as the basis for the decision. If the decision involves an adverse determination, the notice must provide:
(i)all specific reasons for the adverse determination, including the denial code and its corresponding meaning, as well as a description of the health insurance issuer’s standard, if any, that was used in reaching the denial;
(ii)the reference to the specific plan provisions on which the determination is based;
(iii)if the adverse determination is based on incomplete documentation, a description of any additional material or information necessary for the covered person to complete the request, including an explanation of why the material or information is necessary to complete the request;
(iv)a copy of any internal rule, guideline, protocol, or other similar criteria if relied on by the health insurance issuer to make the adverse determination. Alternatively, the health insurance issuer may provide a statement that a specific rule, guideline, protocol, or other similar criteria was relied on to make the adverse determination and that a copy of the rule, guideline, protocol, or other similar criteria will be provided free of charge to the covered person on request.
(v)an explanation of the scientific or clinical judgment used for making the adverse determination if the adverse determination is based on a medical necessity or experimental or investigational treatment or similar exclusion or limit. The explanation must apply the terms of the health plan to the covered person’s medical circumstances. Alternatively, the health insurance issuer may provide a statement that an explanation will be provided to the covered person free of charge on request.
(vi)instructions for requesting any of the following that are applicable:
(A)a copy of the rule, guideline, protocol, or other similar criteria relied on in making the adverse determination in accordance with subsection (8)(f)(iv); or
(B)the written statement of the scientific or clinical rationale for the adverse determination in accordance with subsection (8)(f)(v);
(vii)a statement describing the procedures for obtaining an independent external review of the adverse determination pursuant to Title 33, chapter 32, part 4;
(viii)the following statement, if applicable:
“You and your plan may have other voluntary alternative dispute resolution options, such as mediation. One way to find out what may be available is to contact your state insurance commissioner.”
(ix)a statement indicating the covered person’s right to bring a civil action in a court of competent jurisdiction; and
(x)a notice of the covered person’s right to contact the commissioner’s office for assistance at any time, including the telephone number and address of the commissioner’s office.
(9)The notice under subsection (8)(f) must be provided in accordance with federal regulations and as provided in 33-32-211(9).
(10)(a) A health insurance issuer may provide the notice required under this section orally, in writing, or electronically.
(b)If notice of the adverse determination is provided orally, the health insurance issuer shall provide written or electronic notice of the adverse determination within 3 days after the oral notification.