Montana Code 33-32-105. Application — exemptions
33-32-105. Application — exemptions. (1) Except as provided in subsections (2) and (3), the provisions of this chapter apply to:
Terms Used In Montana Code 33-32-105
- Health care services: means services for the diagnosis, prevention, treatment, cure, or relief of a health condition, illness, injury, or disease, including the provision of pharmaceutical products or services or durable medical equipment. See Montana Code 33-32-102
- Health insurance issuer: has the meaning provided in 33-22-140. See Montana Code 33-32-102
- Prospective review: means a utilization review conducted of a preservice claim prior to an admission or a course of treatment. See Montana Code 33-32-102
- 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
- Retrospective review: means a review of medical necessity conducted after services have been provided to a covered person. 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
- Utilization review organization: means an entity that conducts utilization review for one or more of the following:
(a)an employer with employees who are covered under a health benefit plan or health insurance policy;
(b)a health insurance issuer providing review for its own health plans or for the health plans of another health insurance issuer;
(c)a preferred provider organization or health maintenance organization; and
(d)any other individual or entity that provides, offers to provide, or administers hospital, outpatient, medical, or other health benefits to a person treated by a health care provider under a policy, plan, or contract. See Montana Code 33-32-102
(a)a health insurance issuer that offers a health plan and provides or performs utilization review services;
(b)any designee of the health insurance issuer or utilization review organization that performs utilization review functions on the health insurance issuer’s behalf; and
(c)a health insurance issuer or its designated utilization review organization that provides or performs prospective review or retrospective review benefit determinations.
(2)A general in-house utilization review for a health care provider, including an in-house utilization review that is conducted by or for a long-term care facility and that is required by regulations for medicare or medicaid, is exempt from the provisions of this chapter as long as the review does not directly result in the approval or denial of payment for health care services for a particular case.
(3)A peer review procedure conducted by a professional society or association of providers is exempt from the provisions of this chapter.