Montana Code 33-32-423. Disclosure requirements
33-32-423. Disclosure requirements. (1) Each health insurance issuer shall include a description of the external review procedures in or attached to the policy, certificate, membership booklet, outline of coverage, or other evidence of coverage provided to covered persons.
Terms Used In Montana Code 33-32-423
- 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
- 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
- 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
(2)The disclosure required under subsection (1) must:
(a)be in a format prescribed by the commissioner; and
(b)include a statement that informs the covered person of the right of the covered person or, if applicable, the covered person’s authorized representative to file a request for an external review of an adverse determination or final adverse determination with the health insurance issuer. The statement may explain that external review is available when the adverse determination or final adverse determination involves an issue of medical necessity, appropriateness, health care setting, level of care, or level of effectiveness. The statement must include the telephone number and address of the commissioner.
(3)In addition to the requirements under subsection (2), the statement must inform the covered person that, when filing a request for an external review, the covered person or, if applicable, the covered person’s authorized representative is required to authorize the release of any medical records of the covered person that may be required to be reviewed for the purpose of reaching a decision on the external review.