Montana Code 33-22-1904. Self-referral for obstetrical or gynecological care permitted
33-22-1904. Self-referral for obstetrical or gynecological care permitted. (1) A health benefit plan must permit self-referral to any participating obstetrician or gynecologist by a covered person who has not selected a participating obstetrician or gynecologist as the covered person‘s primary care physician for services covered under the health benefit plan. This self-referral is for the purpose of receiving any obstetrical or gynecological examination or care and primary and preventative obstetrical and gynecological services required as a result of any obstetrical or gynecological examination or condition. This self-referral must be allowed without prior authorization or precertification from the health benefit plan or covered person’s primary care physician, but the health benefit plan may require the covered person to notify the plan prior to self-referral.
Terms Used In Montana Code 33-22-1904
- Covered person: means a policyholder, subscriber, certificate holder, enrollee, or other individual who is participating in a health benefit plan. See Montana Code 33-22-1902
- Health benefit plan: means any individual or group plan, policy, certificate, subscriber contract, contract of insurance provided by a managed care plan, preferred provider agreement, or health maintenance organization subscriber contract that is issued, delivered, issued for delivery, or renewed in this state by a health carrier that pays for, purchases, or furnishes health care services to covered persons who receive health care services in this state. See Montana Code 33-22-1902
- Obstetrician or gynecologist: means a physician who is board-eligible or board-certified by the American board of obstetrics and gynecology. See Montana Code 33-22-1902
- Participating obstetrician or gynecologist: means an obstetrician or gynecologist who is employed by or under contract with a health benefit plan. See Montana Code 33-22-1902
- Person: includes a corporation or other entity as well as a natural person. See Montana Code 1-1-201
- Primary care physician: means a physician who has the responsibility for providing initial and primary care to patients, for maintaining the continuity of patient care, and for initiating referrals for specialist care. See Montana Code 33-22-1902
(2)The services covered by this section may be limited to those services defined by the most recent published recommendations of the American college of obstetricians and gynecologists. The self-referral permitted by this section may be limited to one participating obstetrician or gynecologist for obstetrical care and one participating obstetrician or gynecologist for gynecological care of the covered person’s choice annually.
(3)The participating obstetrician or gynecologist and the covered person shall comply with the health benefit plan’s coordination and referral policies. The health benefit plan may require the participating obstetrician or gynecologist to whom the covered person self-refers to discuss with the covered person’s primary care physician any services or treatment the participating obstetrician or gynecologist recommends for the covered person.
(4)Self-referral under this section may not affect the covered person’s coverage under the health benefit plan. It is the intent of this section that a covered person must at all times have direct access to the covered services of the participating obstetrician or gynecologist of the covered person’s choice under any health benefit plan.