Montana Code 33-36-209. Use of intermediaries — responsibilities of health carriers, intermediaries, and providers
33-36-209. Use of intermediaries — responsibilities of health carriers, intermediaries, and providers. (1) A health carrier is responsible for complying with applicable provisions of this chapter and contracting with an intermediary for all or some of the services for which a health carrier is responsible does not relieve the health carrier of responsibility for compliance.
Terms Used In Montana Code 33-36-209
- Contract: A legal written agreement that becomes binding when signed.
- Covered benefits: means those health care services to which a covered person is entitled under the terms of a health benefit plan. 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
- Network: means the group of participating providers that provides health care services to a managed care plan. See Montana Code 33-36-103
- Obligation: An order placed, contract awarded, service received, or similar transaction during a given period that will require payments during the same or a future period.
- Participating provider: means a provider who, under a contract with a health carrier or with the health carrier's contractor, subcontractor, or intermediary, has agreed to provide health care services to covered persons with an expectation of receiving payment, other than coinsurance, copayments, or deductibles, directly or indirectly from the health carrier. See Montana Code 33-36-103
- provider: means a health care professional or a facility. See Montana Code 33-36-103
- 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
(2)A health carrier may determine whether a subcontracted provider participates in the provider’s own network or a contracted network for the purpose of providing covered benefits to the health carrier’s covered persons.
(3)A health carrier shall maintain copies of all intermediary health care subcontracts at the health carrier’s principal place of business in this state or ensure that the health carrier has access to all intermediary subcontracts, including the right to make copies of the contracts, upon 20 days’ prior written notice from the health carrier.
(4)If required in a contract or otherwise by a health carrier, an intermediary shall transmit utilization documentation and claims-paid documentation to the health carrier. The health carrier shall monitor the timeliness and appropriateness of payments made to providers and health care services received by covered persons. This duty may not be delegated to an intermediary by a health carrier.
(5)If required in a contract or otherwise by a health carrier, an intermediary shall maintain the books, records, financial information, and documentation of services provided to covered persons at its principal place of business in the state and preserve them for 5 years in a manner that facilitates regulatory review.
(6)An intermediary shall allow the commissioner access to the intermediary’s books, records, claim information, billing information, and other documentation of services provided to covered persons that are required by any of those entities to determine compliance with this part and the rules implementing this part.
(7)A health carrier may, in the event of the intermediary’s insolvency, require the assignment to the health carrier of the provisions of a participating provider‘s contract addressing the participating provider’s obligation to furnish covered benefits.