Montana Code 33-32-106. Disclosure of utilization review requirements — drug benefit information
33-32-106. Disclosure of utilization review requirements — drug benefit information. (1) A utilization review organization shall make its current utilization review plan prepared pursuant to 33-32-103, including clinical review criteria, standards, procedures, requirements, and restrictions, readily accessible on its website to covered persons, prospective covered persons, and health care providers. The utilization review plan must be described in detail and in easily understandable language.
Terms Used In Montana Code 33-32-106
- 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
- Health insurance issuer: has the meaning provided in 33-22-140. 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
- Writing: includes printing. See Montana Code 1-1-203
(2)If a utilization review organization intends to implement a new or amended utilization review plan, including any new or amended clinical review criteria, standards, procedures, requirements, or restrictions, the entity may not implement the change until it has:
(a)notified health care providers in writing of the new or amended utilization review plan, including any new or amended clinical review criteria, standards, procedures, requirements, or restrictions, no less than 60 days before the new or amended plan is to be implemented; and
(b)updated its website to reflect the new or amended utilization review plan, including any new or amended clinical review criteria, standards, procedures, requirements, or restrictions, to make the information accessible to covered persons, prospective covered persons, and health care providers.
(3)A health insurance issuer or utilization review organization, as applicable, shall display on its public website current prescription drug benefit information, including formulary lists of each prescription drug covered under the health insurance issuer’s plan.