Terms Used In Montana Code > Title 33 > Chapter 32 - Health Utilization Review

• Ambulatory review: means a utilization review of health care services performed or provided in an outpatient setting. See Montana Code 33-32-102
• Amendment: A proposal to alter the text of a pending bill or other measure by striking out some of it, by inserting new language, or both. Before an amendment becomes part of the measure, thelegislature must agree to it.
• 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

• benefits: means those health care services to which a covered person is entitled under the terms of a health plan. See Montana Code 33-32-102
• Case management: means a coordinated set of activities conducted for individual patient management of serious, complicated, protracted, or otherwise complex health conditions. See Montana Code 33-32-102
• Certification: 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 has been reviewed and, based on the information provided, satisfies the health insurance issuer's requirements for medical necessity, appropriateness, health care setting, level of care, and level of effectiveness. 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
• Commission: means the commission on courts of limited jurisdiction established by the supreme court. See Montana Code 3-1-1501
• Complaint: A written statement by the plaintiff stating the wrongs allegedly committed by the defendant.
• Concurrent review: means a utilization review conducted during a patient's stay or course of treatment in a facility, the office of a health care professional, or another inpatient or outpatient health care setting. See Montana Code 33-32-102
• Contract: A legal written agreement that becomes binding when signed.
• Corporation: A legal entity owned by the holders of shares of stock that have been issued, and that can own, receive, and transfer property, and carry on business in its own name.
• 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
• Discharge planning: means the formal process for determining, prior to discharge from a facility, the coordination and management of the care that a patient receives after discharge from a facility. See Montana Code 33-32-102
• Emergency medical condition: has the meaning provided in 33-36-103. See Montana Code 33-32-102
• Emergency services: has the meaning provided in 33-36-103. 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 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
• Judge: means :

  (a)a municipal court judge;

  (b)a justice of the peace; or

  (c)a city judge. See Montana Code 3-1-1501

• Jurisdiction: (1) The legal authority of a court to hear and decide a case. Concurrent jurisdiction exists when two courts have simultaneous responsibility for the same case. (2) The geographic area over which the court has authority to decide cases.
• Litigation: A case, controversy, or lawsuit. Participants (plaintiffs and defendants) in lawsuits are called litigants.
• 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

• Network: means the group of participating providers providing services to a managed care plan. See Montana Code 33-32-102
• Oversight: Committee review of the activities of a Federal agency or program.
• Participating provider: means a health care provider who, under a contract with a health insurance issuer or with its contractor or subcontractor, has agreed to provide health care services to covered persons with the expectation of receiving payment, other than coinsurance, copayments, or deductibles, directly or indirectly from the health insurance issuer. See Montana Code 33-32-102
• Partnership: A voluntary contract between two or more persons to pool some or all of their assets into a business, with the agreement that there will be a proportional sharing of profits and losses.
• 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
• Person: includes a corporation or other entity as well as a natural person. See Montana Code 1-1-201
• Preservice claim: means a request for benefits or payment from a health insurance issuer for health care services that, under the terms of the health insurance issuer's contract of coverage, requires authorization from the health insurance issuer or from the health insurance issuer's designated utilization review organization prior to receiving the services. 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
• Prospective review: means a utilization review conducted of a preservice claim prior to an admission or a course of treatment. See Montana Code 33-32-102
• 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

• Rescission: means a cancellation or the discontinuance of coverage under a health plan that has a retroactive effect. See Montana Code 33-32-102
• Rescission: The cancellation of budget authority previously provided by Congress. The Impoundment Control Act of 1974 specifies that the President may propose to Congress that funds be rescinded. If both Houses have not approved a rescission proposal (by passing legislation) within 45 days of continuous session, any funds being withheld must be made available for obligation.
• Retrospective review: means a review of medical necessity conducted after services have been provided to a covered person. See Montana Code 33-32-102
• Stabilize: means , with respect to an emergency condition, to ensure that no material deterioration of the condition is, within a reasonable medical probability, likely to result from or occur during the transfer of the individual from a facility. See Montana Code 33-32-102
• Uphold: The decision of an appellate court not to reverse a lower court decision.
• Urgent care request: means a request for a health care service or course of treatment with respect to which the time periods for making a nonurgent care request determination could:

  (i)seriously jeopardize the life or health of the covered person or the ability of the covered person to regain maximum function; or

  (ii)subject the covered person, in the opinion of a health care provider with knowledge of the covered person's medical condition, to severe pain that cannot be adequately managed without the health care service or treatment that is the subject of the request. 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