Montana Code 33-32-402. Definitions for external review
33-32-402. Definitions for external review. For the purposes of this part, the following definitions apply:
Terms Used In Montana Code 33-32-402
- 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
- Evidence: Information presented in testimony or in documents that is used to persuade the fact finder (judge or jury) to decide the case for one side or the other.
- External review: describes the set of procedures provided for in Title 33, chapter 32, part 4. See Montana Code 33-32-102
- 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
- Medical necessity: means health care services that a health care provider exercising prudent clinical judgment would provide to a patient for the purpose of preventing, evaluating, diagnosing, treating, curing, or relieving a health condition, illness, injury, or disease or its symptoms and that are:
(a)in accordance with generally accepted standards of practice;
(b)clinically appropriate in terms of type, frequency, extent, site, and duration and are considered effective for the patient's illness, injury, or disease; and
(c)not primarily for the convenience of the patient or health care provider and not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of the patient's illness, injury, or disease. 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
- United States: includes the District of Columbia and the territories. See Montana Code 1-1-201
- 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
(1)”Adverse determination” 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 that is a covered benefit has been reviewed and, based on the information provided, does not meet the health insurance issuer’s requirements for medical necessity, appropriateness, health care setting, level of care, or level of effectiveness and as a result the requested service or payment for the service has been denied, reduced, or terminated.
(2)”Best evidence” means evidence based on:
(a)randomized clinical trials;
(b)a cohort study or case-control study if randomized clinical trials are not available;
(c)a case series if information as provided in subsection (2)(a) or (2)(b) is unavailable; or
(d)an expert opinion if information as provided in subsection (2)(a), (2)(b), or (2)(c) is unavailable.
(3)”Case-control study” means a retrospective evaluation of two groups of patients with different outcomes to determine which specific interventions the patients received.
(4)”Case series” means an evaluation of a series of patients with a particular outcome, without the use of a control group.
(5)”Cohort study” means a prospective evaluation of two groups of patients with only one group of patients receiving a specific intervention.
(6)”Disclose” means to release, transfer, or otherwise divulge protected health information to any person other than the individual who is the subject of the protected health information.
(7)”Evidence-based standard” means the conscientious, explicit, and judicious use of the current best evidence based on the overall systematic review of the research in making decisions about the care of individual patients.
(8)”Expert opinion” means a belief or an interpretation by specialists with experience in a specific area about the scientific evidence pertaining to a particular service, intervention, or therapy.
(9)”Health information” means information or data, whether oral or recorded in any form or medium, including personal facts or information about events or relationships that relate to:
(a)the past, present, or future physical, mental, or behavioral health or condition of a covered person or a member of the covered person’s family;
(b)the provision of health care services to a covered person; or
(c)payment for the provision of health care services to a covered person.
(10)”Independent review organization” means an entity that conducts independent external reviews of adverse determinations and final adverse determinations.
(11)”Medical or scientific evidence” means evidence found in the following sources:
(a)peer-reviewed scientific studies published in or accepted for publication by medical journals that meet nationally recognized requirements for scientific manuscripts and that submit most of their published articles for review by experts who are not part of the editorial staff;
(b)peer-reviewed medical literature, including literature relating to therapies reviewed and approved by a qualified institutional review board, biomedical compendia, and other medical literature that meet the criteria of the national institutes of health’s library of medicine for indexing in Index Medicus and Excerpta Medica, published by the Reed Elsevier group;
(c)medical journals recognized by the secretary of health and human services under 42 U.S.C. § 1395x(t)(2)(B) of the federal Social Security Act;
(d)the following standard reference compendia:
(i)the American Hospital Formulary Service Drug Information;
(ii)Drug Facts and Comparisons;
(iii)the American Dental Association Guide to Dental Therapeutics; and
(iv)the United States Pharmacopeia;
(e)findings, studies, or research conducted by or under the auspices of federal government agencies and nationally recognized federal research institutes, including:
(i)the federal agency for healthcare research and quality;
(ii)the national institutes of health;
(iii)the national cancer institute;
(iv)the national academy of sciences;
(v)the centers for medicare and medicaid services;
(vi)the food and drug administration; and
(vii)any national board recognized by the national institutes of health for the purpose of evaluating the medical value of health care services; or
(f)any other medical or scientific evidence that is comparable to the sources listed in subsection (11)(d) or (11)(e).
(12)”NAIC” means the national association of insurance commissioners.
(13)”Protected health information” means health information:
(a)that identifies an individual who is the subject of the information; or
(b)with respect to which there is a reasonable basis to believe that the information could be used to identify an individual.
(14)”Randomized clinical trial” means a controlled, prospective study of patients who have been assigned at random to an experimental group or a control group at the beginning of the study with only the experimental group of patients receiving a specific intervention. The term includes a study of the groups for variables and anticipated outcomes over time.