Terms Used In Montana Code > Title 33 > Chapter 32 > Part 1 - General Provisions

• Ambulatory review: means a utilization review of health care services performed or provided in an outpatient setting. 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 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
• 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
• 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
• 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

• 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
• 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

• Retrospective review: means a review of medical necessity conducted after services have been provided to a covered person. See Montana Code 33-32-102
• State: when applied to the different parts of the United States, includes the District of Columbia and the territories. See Montana Code 1-1-201
• United States: includes the District of Columbia and the territories. See Montana Code 1-1-201
• 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