Terms Used In Montana Code > Title 33 > Chapter 32 > Part 3 - Grievance Procedures

• 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
• 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.
• 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
• 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 insurance issuer: has the meaning provided in 33-22-140. See Montana Code 33-32-102
• 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

• Oversight: Committee review of the activities of a Federal agency or program.
• 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
• 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
• 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
• Writing: includes printing. See Montana Code 1-1-203