Terms Used In Montana Code > Title 33 > Chapter 32 > Part 4 - External Review

• 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
• 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
• 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 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

• 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
• 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.
• 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