Montana Code 33-32-103. Utilization review plan
33-32-103. Utilization review plan. An entity covered under the provisions of this chapter may not conduct a utilization review of health care services provided or to be provided to a patient covered under a contract or plan for health care services issued in this state unless that entity, at all times, maintains and can provide at the commissioner’s request a current utilization review plan that includes:
Terms Used In Montana Code 33-32-103
- Contract: A legal written agreement that becomes binding when signed.
- 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
- 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
- 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
(1)a description of review criteria, standards, and procedures to be used in evaluating proposed or delivered health care services that, to the extent possible, must:
(a)be based on nationally recognized criteria, standards, and procedures;
(b)reflect community standards of care, except that a utilization review plan for health care services under the medicaid program provided for in Title 53 need not reflect community standards of care;
(c)ensure quality of care; and
(d)ensure access to needed health care services;
(2)policies and procedures to ensure that a representative of the entity conducting the utilization review is reasonably accessible to patients and health care providers at all times;
(3)policies and procedures to ensure compliance with all applicable state and federal laws to protect the confidentiality of individual medical records;
(4)a copy of the materials designed to inform applicable patients and health care providers of the requirements of the utilization review plan; and
(5)any other information that may be required by the commissioner that is necessary to implement this chapter.