33-32-410. Standard external review. (1) Within 120 days after the date of receipt of a notice of an adverse determination or a final adverse determination pursuant to 33-32-403, a covered person or, if applicable, the covered person‘s authorized representative may file a request for an external review with the health insurance issuer.

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Terms Used In Montana Code 33-32-410

  • Appeal: A request made after a trial, asking another court (usually the court of appeals) to decide whether the trial was conducted properly. To make such a request is "to appeal" or "to take an appeal." One who appeals is called the appellant.
  • Authorized representative: means :

    (a)a person to whom a covered person has given express written consent to represent the covered person;

    (b)a person authorized by law to provided substituted consent for a covered person; or

    (c)a family member of the covered person, or the covered person's treating health care provider, only if the covered person is unable to provide consent. See Montana Code 33-32-102

  • Clinical peer: means a physician or other health care provider who:

    (a)holds a nonrestricted license in a state of the United States; and

    (b)is trained or works in the same or a similar specialty to the specialty that typically manages the medical condition, procedure, or treatment under review. See Montana Code 33-32-102

  • 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
  • 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
  • Final adverse determination: means an adverse determination involving a covered benefit that has been upheld by a health insurance issuer or its designated utilization review organization at the completion of the health insurance issuer's internal grievance process as provided in Title 33, chapter 32, part 3. See Montana Code 33-32-102
  • Grievance: means a written complaint or an oral complaint if the complaint involves an urgent care request submitted by or on behalf of a covered person regarding:

    (a)availability, delivery, or quality of health care services, including a complaint regarding an adverse determination made pursuant to utilization review;

    (b)claims payment, handling, or reimbursement for health care services; or

    (c)matters pertaining to the contractual relationship between a covered person and a health insurance issuer. 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
  • Process: means a writ or summons issued in the course of judicial proceedings. See Montana Code 1-1-202
  • 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
  • Uphold: The decision of an appellate court not to reverse a lower court decision.
  • 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)Within 5 business days after the date of receipt of the external review request, the health insurance issuer shall complete a preliminary review of the request to determine whether:

(a)the individual is or was a covered person in the health plan at the time the health care service or treatment was requested or, in the case of a retrospective review, was a covered person in the health plan at the time the health care service or treatment was provided;

(b)the health care service or treatment that is the subject of the adverse determination or the final adverse determination is a covered service under the covered person’s health plan but is not covered because of a determination by the health insurance issuer that the health care service or treatment does not meet the health insurance issuer’s requirements for medical necessity, appropriateness, health care setting, level of care, or level of effectiveness;

(c)the covered person has exhausted the health insurance issuer’s internal grievance process as set forth in Title 33, chapter 32, part 3, or the covered person is exempt under 33-32-307(2); and

(d)the covered person or the covered person’s authorized representative has provided all of the information and forms required to process an external review.

(3)(a) Within 1 business day after completion of the preliminary review, the health insurance issuer shall notify the covered person or, if applicable, the covered person’s authorized representative in writing as to whether:

(i)the request is complete; and

(ii)the request is eligible for external review.

(b)(i) If the request is not complete, the health insurance issuer shall inform the covered person or, if applicable, the covered person’s authorized representative in writing and include in the notice the information or materials that are needed to make the request complete.

(ii)If the request is not eligible for external review, the health insurance issuer shall inform the covered person or, if applicable, the covered person’s authorized representative in writing and include in the notice the reasons for the request’s ineligibility.

(4)(a) The commissioner may specify the form for the health insurance issuer’s notice of initial determination under subsection (3) and any supporting information to be included in the notice.

(b)The notice of initial determination provided under subsection (3) must include a statement informing the covered person or, if applicable, the covered person’s authorized representative of the right to appeal to the commissioner a health insurance issuer’s initial determination that the external review request is ineligible for review.

(5)(a) If the commissioner receives an appeal under subsection (4), the commissioner may require a referral for external review, notwithstanding a health insurance issuer’s initial determination that the request is ineligible.

(b)A determination by the commissioner under subsection (5)(a) must be based on the terms of the covered person’s health plan and all applicable provisions of Title 33, chapter 32, parts 2 through 4.

(6)(a) If the request is eligible for external review, the health insurance issuer shall within 1 business day assign an independent review organization on a random basis, or using another method of assignment that ensures the independence and impartiality of the assignment process, from the list of approved independent review organizations compiled and maintained by the commissioner pursuant to 33-32-416 to conduct the external review.

(b)In making the assignment, the health insurance issuer shall consider whether an independent review organization is qualified to conduct the particular external review based on the nature of the health care service or treatment that is the subject of the adverse determination or final adverse determination.

(c)The health insurance issuer shall also take into account other circumstances, including conflict of interest concerns pursuant to 33-32-417(4).

(7)The assigned independent review organization, in reaching its decision, is not bound by any decisions or conclusions reached during the health insurance issuer’s utilization review process set forth in Title 33, chapter 32, part 2, or the health insurance issuer’s internal grievance process set forth in Title 33, chapter 32, part 3.

(8)Within 1 business day of assigning an independent review organization pursuant to subsection (6), the health insurance issuer shall notify, in writing, the covered person or, if applicable, the covered person’s authorized representative that the health insurance issuer initiated an external review.

(9)The health insurance issuer shall include in the notice provided to the covered person or, if applicable, the covered person’s authorized representative a statement that the covered person or the covered person’s authorized representative may submit in writing to the assigned independent review organization within 10 business days following the date of receipt of the notice provided pursuant to subsection (8) any additional information for the independent review organization to consider when conducting the external review. The independent review organization shall accept and consider information submitted within 10 business days after the date of receipt of the notice and may accept and consider additional information submitted after the 10 business days.

(10)Within 5 business days after assigning an independent review organization pursuant to subsection (6), the health insurance issuer or its designated utilization review organization shall provide to the assigned independent review organization the medical records, documents, and any information used in making the adverse determination or final adverse determination.

(11)Except as provided in subsection (12), failure by the health insurance issuer or its designated utilization review organization to provide the documents and information within the time specified in subsection (10) may not delay the conduct of the external review.

(12)(a) If the health insurance issuer or its designated utilization review organization fails to provide the documents and information within the time specified in subsection (10), the assigned independent review organization may terminate the external review and make a decision to reverse the adverse determination or final adverse determination.

(b)Within 1 business day after making a decision under subsection (12)(a), the independent review organization shall notify the covered person or, if applicable, the covered person’s authorized representative as well as the health insurance issuer.

(13)If the provisions of subsection (12) do not apply, the assigned independent review organization shall review all of the information and documents received pursuant to subsection (10) and any other information submitted in writing to the independent review organization by the covered person or, if applicable, the covered person’s authorized representative pursuant to subsection (9).

(14)On receipt of any information submitted by the covered person or, if applicable, the covered person’s authorized representative pursuant to subsection (9), the assigned independent review organization shall within 1 business day after receipt forward the information to the health insurance issuer.

(15)On receipt of the information, if any, forwarded as provided in subsection (14), the health insurance issuer may reconsider its adverse determination or final adverse determination that is the subject of the external review.

(16)Reconsideration by the health insurance issuer of its adverse determination or final adverse determination pursuant to subsection (15) may not delay or terminate the external review.

(17)The external review may be terminated only if the health insurance issuer decides, on completion of its reconsideration, to reverse its adverse determination or final adverse determination and provide coverage or payment for the health care service or treatment that is the subject of the adverse determination or final adverse determination.

(18)(a) Within 1 business day after making a decision to reverse its adverse determination or final adverse determination, as provided in subsection (17), the health insurance issuer shall notify the following in writing of its decision:

(i)the covered person or, if applicable, the covered person’s authorized representative; and

(ii)the assigned independent review organization.

(b)The assigned independent review organization shall terminate the external review on receipt of the notice from the health insurance issuer sent pursuant to subsection (18)(a).

(19)In addition to the documents and information provided pursuant to subsection (10), the assigned independent review organization shall consider the following information and documents in making a decision, to the extent the information or documents are available:

(a)the covered person’s medical records;

(b)the attending health care professional’s recommendation;

(c)consulting reports from appropriate health care professionals and other documents submitted by the health insurance issuer, the covered person, the covered person’s authorized representative, or the covered person’s treating health care provider;

(d)the terms of coverage under the covered person’s health plan with the health insurance issuer to ensure that the independent review organization’s decision is not contrary to the terms of coverage under the covered person’s health plan with the health insurance issuer;

(e)the most appropriate practice guidelines, which must include generally accepted practice guidelines, evidence-based standards, or any other practice guidelines developed by the federal government or national or professional medical societies, boards, and associations;

(f)any applicable clinical review criteria developed and used by the health insurance issuer or its designated utilization review organization; and

(g)the opinion of the independent review organization’s clinical peer after considering the provisions of subsections (19)(a) through (19)(f) to the extent the information or documents are available.

(20)Within 45 days after the date of receipt of the request for an external review, the assigned independent review organization shall provide written notice of its decision to uphold or reverse the adverse determination or the final adverse determination to:

(a)the covered person or, if applicable, the covered person’s authorized representative; and

(b)the health insurance issuer.

(21)The independent review organization shall include in the notice sent pursuant to subsection (20):

(a)a general description of the reason for the request for the external review;

(b)the date the independent review organization received the assignment from the health insurance issuer to conduct the external review;

(c)the time period over which the external review was conducted;

(d)the date of the independent review organization’s decision;

(e)the principal reasons for the decision;

(f)the rationale for the decision; and

(g)references to the evidence or documentation, including the evidence-based standards, considered in reaching the decision.

(22)If a notice of a decision under subsection (20) reverses the adverse determination or final adverse determination, the health insurance issuer shall immediately approve the coverage that was the subject of the adverse determination or final adverse determination.

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