Montana Code 53-6-1404. Peer review of overpayment findings
53-6-1404. Peer review of overpayment findings. (1) (a) A provider‘s request for an administrative review of an overpayment determination may include a request for peer review of any clinical or professional judgment upon which the overpayment determination relies. A clinical or professional judgment includes but is not limited to any clinical or professional judgment upon which the provider’s evaluation, treatment, records, coding, or billing is based.
Terms Used In Montana Code 53-6-1404
- 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.
- Department: means the department of public health and human services provided for in 2-15-2201. See Montana Code 53-6-1401
- Overpayment determination: means a determination by the department or an auditor that forms the basis for or results in the department:
(a)partially or completely reducing a medicaid payment to a provider for a claim;
(b)demanding that the provider repay all or a part of a payment for a claim; or
(c)using or applying any other method to recoup, recover, or collect from a provider all or part of a payment for a claim. See Montana Code 53-6-1401
- Peer: means a health care provider who is employed by or under contract with the department or an auditor and who:
(a)has substantially the same education and training, provides or has provided substantially the same range of health care services, and has the same license to practice as the provider who is the subject of an overpayment audit; or
(b)is an expert in the medical, dental, mental health, behavioral health, or other health care provider decisionmaking that is at issue in the overpayment audit. See Montana Code 53-6-1401
- Provider: means an individual, company, partnership, corporation, institution, facility, or other entity or business association that has enrolled or applied to enroll as a provider of services or items under the medical assistance program established under this chapter. See Montana Code 53-6-1401
- Records: means medical, professional, business, or financial information and documents, whether in written, electronic, magnetic, microfilm, or other form:
(i)pertaining to the provision of treatment, care, services, or items to an individual receiving services under the medicaid program;
(ii)pertaining to the income and expenses of the provider; or
(iii)otherwise relating to or pertaining to a determination of eligibility for or entitlement to payment or reimbursement under the medicaid program. See Montana Code 53-6-1401
- Writing: includes printing. See Montana Code 1-1-203
(b)The provider’s peer review request must identify each clinical or professional judgment to be reviewed and include a statement of the provider’s opinion regarding the identified clinical or professional judgment.
(2)If a provider requests peer review, the department shall obtain and consider as part of its administrative review a peer review of each clinical or professional judgment upon which the overpayment determination relied. The department shall mail a copy of the peer review to the provider within 10 days of receipt. The department may not issue its administrative review determination or demand or collect repayment of the alleged overpayment until the department has obtained and considered the peer review.
(3)If at any time during an administrative review, appeal, or other legal proceedings regarding an overpayment determination the department relies on a clinical or professional judgment not identified in the initial notice of overpayment determination and for which a peer review was not previously requested, obtained, or considered, the provider may request in writing that peer review be conducted in accordance with this section. The proceedings must be suspended or stayed until the department has obtained, considered, and responded in writing to the peer review.