Montana Code 33-32-403. Notice of right to external review
33-32-403. Notice of right to external review. (1) A health insurance issuer shall:
Terms Used In Montana Code 33-32-403
- 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
- Certification: means a determination by a health insurance issuer or its designated utilization review organization that an admission, availability of care, continued stay, or other health care service has been reviewed and, based on the information provided, satisfies the health insurance issuer's requirements for medical necessity, appropriateness, health care setting, level of care, and level of effectiveness. See Montana Code 33-32-102
- 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
- External review: describes the set of procedures provided for in Title 33, chapter 32, part 4. See Montana Code 33-32-102
- Final adverse determination: means an adverse determination involving a covered benefit that has been upheld by a health insurance issuer or its designated utilization review organization at the completion of the health insurance issuer's internal grievance process as provided in Title 33, chapter 32, part 3. 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
- 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
- Utilization review: means a set of formal techniques designed to monitor the use of or to evaluate the clinical necessity, appropriateness, efficacy, or efficiency of health care services, procedures, or settings. See Montana Code 33-32-102
- Writing: includes printing. See Montana Code 1-1-203
(a)notify the covered person or, if applicable, the covered person‘s authorized representative in writing of the covered person’s right to request an external review pursuant to 33-32-410, 33-32-411, or 33-32-412; and
(b)include the appropriate statements and information described in subsection (4) at the same time that the health insurance issuer sends written notice of:
(i)an adverse determination upon completion of the health insurance issuer’s utilization review process described in Title 33, chapter 32, part 2; and
(ii)a final adverse determination.
(2)The health insurance issuer shall include in the written notice required under subsection (1) the following, or substantially equivalent, language:
“We have denied your request for the provision of or payment for a health care service or course of treatment. You have the right to have our decision reviewed by health care professionals who have no association with us if our decision involved making a judgment as to the medical necessity, appropriateness, health care setting, level of care, or level of effectiveness of the health care service or treatment you requested. You may exercise this right by submitting a request for external review to us [insert address and telephone number of the unit of the health insurance issuer that administers the external review program].”
(3)(a) The commissioner may prescribe the form and content of the notice required under this section.
(b)The notice must also include the following information:
(i)information sufficient to identify the claim involved, including the date of service, the health care provider, and, if applicable, the claim amount; and
(ii)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 for an external review as outlined in this part.
(4)The health insurance issuer shall include in the notice required under subsection (1) a statement that:
(a)for a notice related to an adverse determination:
(i)the covered person or, if applicable, the covered person’s authorized representative may file a grievance under the health insurance issuer’s internal grievance process provided for in 33-32-308;
(ii)if the health insurance issuer has not issued a written decision to the covered person or the covered person’s authorized representative within the time period provided in 33-32-308 or 33-32-309, as applicable, after the date the covered person or the covered person’s authorized representative files the grievance with the health insurance issuer and the covered person or the covered person’s authorized representative has not requested or agreed to a delay, the covered person or the covered person’s authorized representative may file a request for external review pursuant to 33-32-404. Under those conditions, the covered person or the covered person’s authorized representative is considered to have exhausted the health insurance issuer’s internal grievance process for the purposes of 33-32-307.
(iii)the covered person or the covered person’s authorized representative may file a request for an expedited external review to be conducted pursuant to 33-32-411 or 33-32-412, as applicable, under the following circumstances:
(A)a review under 33-32-411 may be requested if the covered person has a medical condition with regard to which the timeframe for completion of an expedited grievance review of an adverse determination would seriously jeopardize the life or health of the covered person or would jeopardize the covered person’s ability to regain maximum function; and
(B)a review under 33-32-412 may be requested if the adverse determination involves a denial of coverage based on a determination that the recommended or requested health care service or treatment is experimental or investigational and the covered person’s treating health care provider certifies in writing that the recommended or requested health care service or treatment that is the subject of the adverse determination would be significantly less effective if not promptly initiated. The health care provider’s certification must be submitted at the same time that the covered person or the covered person’s authorized representative files a request for an expedited review of a grievance involving an adverse determination. However, the independent review organization assigned to conduct the expedited external review is responsible for determining whether the covered person is required to complete the expedited review of the grievance before the expedited external review can begin.
(iv)informs the covered person or the covered person’s authorized representative of the other exhaustion methods listed in 33-32-405;
(b)for a notice related to a final adverse determination, the covered person or the covered person’s authorized representative may file a request for:
(i)an expedited external review under 33-32-411 if the covered person has a medical condition for which the timeframe for completion of a standard external review under 33-32-410 would seriously jeopardize the life or health of the covered person or would jeopardize the covered person’s ability to regain maximum function;
(ii)an expedited external review under 33-32-411 if the covered person has received emergency services and has not been discharged from a facility and the request concerns an admission, the availability of care, a continued stay, or a health care service for which the covered person received emergency services;
(iii)a standard external review under 33-32-412 if the denial of coverage was based on a determination that the recommended or requested health care service or treatment is experimental or investigational; or
(iv)an expedited external review under 33-32-412 if a covered person to which subsection (4)(b)(iii) applies attaches a written certification from the covered person’s treating health care provider that the recommended or requested health care service or treatment that is the subject of the request would be significantly less effective if not promptly initiated.
(5)In addition to the information to be provided in subsections (1) and (2), the health insurance issuer shall:
(a)include a description of both the standard and the expedited external review procedures as required by the disclosure requirements under 33-32-423, highlighting the provisions in the external review procedures that give the covered person or, if applicable, the covered person’s authorized representative the opportunity to submit additional information and including any forms used to process an external review; and
(b)state that the commissioner’s office is available to assist covered persons with the external review process. This statement must include the commissioner’s contact information.
(6)Among the forms provided under this section, the health insurance issuer shall include an authorization form or other document approved by the commissioner that complies with the requirements of 45 C.F.R. § 164.508 and 33-19-206, by which the covered person, for purposes of conducting an external review under this part, authorizes the health insurance issuer and the covered person’s treating health care provider to disclose protected health information, including medical records, concerning the covered person for the purposes of the external review.