Montana Code 33-32-417. Minimum qualifications for independent review organizations
33-32-417. Minimum qualifications for independent review organizations. (1) To be approved to conduct external reviews as provided in 33-32-416, an independent review organization shall establish and maintain written policies and procedures that govern all aspects of both the standard external review process and the expedited external review process set forth in 33-32-410 through 33-32-412. The written policies and procedures must include, at a minimum:
Terms Used In Montana Code 33-32-417
- 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
- Clinical peer: means a physician or other health care provider who:
(a)holds a nonrestricted license in a state of the United States; and
(b)is trained or works in the same or a similar specialty to the specialty that typically manages the medical condition, procedure, or treatment under review. See Montana Code 33-32-102
- Clinical review criteria: means the written policies, written screening procedures, decision abstracts, determination rules, clinical and medical protocols, practice guidelines, or any other criteria or rationale used by a health insurance issuer or its designated utilization review organization to determine the medical necessity of health care services. 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
- External review: describes the set of procedures provided for in Title 33, chapter 32, part 4. See Montana Code 33-32-102
- Health insurance issuer: has the meaning provided in 33-22-140. 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
- United States: includes the District of Columbia and the territories. See Montana Code 1-1-201
(a)a quality assurance mechanism that ensures:
(i)that external reviews are conducted within the specified timeframes and that required notices are provided in a timely manner;
(ii)that the independent review organization is unbiased;
(iii)both the selection of qualified and impartial clinical peers to conduct external reviews on behalf of the independent review organization and the suitable matching of reviewers to specific cases;
(iv)that the independent review organization employs or contracts with an adequate number of clinical peers to meet the objective of qualified, impartial reviews;
(v)the confidentiality of medical and treatment records as well as clinical review criteria; and
(vi)that any person employed by or under contract with the independent review organization adheres to the requirements of this part;
(b)a toll-free telephone service to receive information related to external reviews on a 24-hour-a-day, 7-day-a-week basis. The telephone service must be capable of accepting, recording, or providing appropriate instruction to incoming telephone callers during other-than-normal business hours.
(c)an agreement to maintain and provide to the commissioner the information required under 33-32-421.
(2)All clinical peers assigned by an independent review organization to conduct external reviews must:
(a)be appropriate health care providers; and
(b)meet the following minimum qualifications:
(i)be an expert in the treatment of the covered person‘s medical condition that is the subject of the external review;
(ii)be knowledgeable about the recommended health care service or treatment through recent or current actual clinical experience treating patients with the same or similar medical conditions of the covered person;
(iii)hold a nonrestricted professional license in a state of the United States and, for physicians, a current certification by a recognized American medical specialty board in one or more areas appropriate to the subject of the external review; and
(iv)have no history of disciplinary actions or sanctions, including participation restrictions or a loss of staff privileges either taken or pending by any hospital, government agency, governmental unit, or regulatory body if the disciplinary actions or sanctions raise a substantial question as to the clinical peer‘s physical, mental, or professional competence or moral character.
(3)In addition to the requirements in subsection (1), an independent review organization may not own or control, be a subsidiary of, or in any way be owned or controlled by or exercise control over a health plan, a health insurance issuer, a national, state, or local trade association of health plans, or a national, state, or local trade association of health care providers.
(4)(a) In addition to the requirements in subsections (1) through (3), to be approved under 33-32-416 to conduct an external review of a specified case, neither the independent review organization selected to conduct the external review nor any clinical peer assigned by the independent review organization to conduct the external review may have a material professional, familial, or financial conflict of interest with any of the following:
(i)the health insurance issuer that is the subject of the external review;
(ii)the covered person whose treatment is the subject of the external review or, if applicable, the covered person’s authorized representative;
(iii)any officer, director, or management employee of the health insurance issuer that is the subject of the external review;
(iv)the health care provider, the health care provider’s medical group, or the independent practice association recommending the health care service or treatment that is the subject of the external review;
(v)the facility at which the recommended health care service or treatment would be provided; or
(vi)the developer or manufacturer of the principal drug, device, procedure, or other therapy being recommended for the covered person whose treatment is the subject of the external review.
(b)In determining whether an independent review organization or a clinical peer assigned by the independent review organization to conduct the external review has a material professional, familial, or financial conflict of interest, the commissioner shall take into consideration:
(i)situations in which the independent review organization to be assigned to conduct an external review of a specified case or a clinical peer to be assigned by the independent review organization to conduct an external review of a specified case may have an apparent professional, familial, or financial relationship or connection with a person described in subsection (4)(a) if the characteristics of that relationship or connection do not pose a material professional, familial, or financial conflict of interest that otherwise would result in the disapproval of the independent review organization or of the clinical peer from conducting the external review; and
(ii)whether other medical expertise is available within a reasonable timeframe.
(5)(a) An independent review organization that is accredited by a nationally recognized private accrediting entity that has independent review accreditation standards determined by the commissioner to be equivalent to or exceed the minimum qualifications of this section is presumed to be in compliance with this section and eligible for approval under 33-32-416. However, the commissioner shall also consider the conflict of interest provisions of subsection (4).
(b)The commissioner shall initially and periodically review the independent review organization accreditation standards of a nationally recognized private accrediting entity to determine whether the entity’s standards are and continue to be equivalent to or exceed the minimum qualifications established under this section. The commissioner may accept a review conducted by the NAIC for the determination under this subsection (5)(b).
(c)On request, a nationally recognized private accrediting entity shall make its current independent review organization accreditation standards available to the commissioner or the NAIC to enable the commissioner to determine if the entity’s standards are equivalent to or exceed the minimum qualifications established under this section. The commissioner may exclude any private accrediting entity that is not reviewed by the NAIC.