Montana Code 33-36-203. Selection of providers — professional credentials standards
33-36-203. Selection of providers — professional credentials standards. (1) A health carrier shall adopt standards for selecting participating providers who are primary care professionals and for each health care professional specialty within the health carrier’s network. The health carrier shall use the standards to select health care professionals, the health carrier’s intermediaries, and any provider network with which the health carrier contracts. A health carrier may not adopt selection criteria that allow the health carrier to:
Terms Used In Montana Code 33-36-203
- Contract: A legal written agreement that becomes binding when signed.
- Health care professional: means a physician or other health care practitioner licensed, accredited, or certified pursuant to the laws of this state to perform specified health care services consistent with state law. See Montana Code 33-36-103
- Health care services: means services for the diagnosis, prevention, treatment, cure, or relief of a health condition, illness, injury, or disease. See Montana Code 33-36-103
- Health carrier: means an entity subject to the insurance laws and rules of this state that contracts, offers to contract, or enters into an agreement to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services, including a disability insurer, health maintenance organization, or health service corporation or another entity providing a health benefit plan. See Montana Code 33-36-103
- Intermediary: means a person authorized to negotiate, execute, and be a party to a contract between a health carrier and a provider or between a health carrier and a network. See Montana Code 33-36-103
- Managed care plan: means a health benefit plan that either requires or creates incentives, including financial incentives, for a covered person to use health care providers managed, owned, under contract with, or employed by a health carrier, but not preferred provider organizations or other provider networks operated in a fee-for-service indemnity environment. See Montana Code 33-36-103
- Network: means the group of participating providers that provides health care services to a managed care plan. See Montana Code 33-36-103
- provider: means a health care professional or a facility. See Montana Code 33-36-103
(a)avoid high-risk populations by excluding a provider because the provider is located in a geographic area that contains populations or providers presenting a risk of higher than average claims, losses, or use of health care services; or
(b)exclude a provider because the provider treats or specializes in treating populations presenting a risk of higher than average claims, losses, or use of health care services.
(2)Subsection (1) does not prohibit a health carrier from declining to select a provider who fails to meet the other legitimate selection criteria of the health carrier adopted in compliance with this part and the rules implementing this part.
(3)This part does not require a health carrier, its intermediary, or a provider network with which the health carrier or its intermediary contract to employ specific providers or types of providers who may meet their selection criteria or to contract with or retain more providers or types of providers than are necessary to maintain an adequate network.
(4)A health carrier may use criteria established in accordance with the provisions of this section to select health care professionals allowed to participate in the health carrier’s managed care plan. A health carrier shall make its selection standards for participating providers available for review by the commissioner and by each health care professional who is subject to the selection standards.