Montana Code 33-32-207. Health insurance issuer duties for utilization review
33-32-207. Health insurance issuer duties for utilization review. (1) A health insurance issuer that requires a request for benefits under the covered person‘s health plan to be subjected to utilization review shall implement a utilization review program with written documentation describing all review activities and procedures, both delegated and nondelegated, for:
Terms Used In Montana Code 33-32-207
- 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
- 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
- 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
- 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
- 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
(a)the filing of benefit requests;
(b)the notification of utilization review and benefit determinations; and
(c)the review of adverse determinations in accordance with Title 33, chapter 32, parts 3 and 4.
(2)The written documentation must describe the following:
(a)procedures to evaluate the medical necessity, appropriateness, efficacy, or efficiency of health care services;
(b)data sources and clinical review criteria used in decisionmaking;
(c)mechanisms to ensure consistent application of clinical review criteria and compatible decisions;
(d)data collection processes and analytical methods used in assessing utilization of health care services;
(e)provisions for ensuring confidentiality of clinical and proprietary information;
(f)the organizational structure that periodically assesses utilization review activities and reports to the health insurance issuer’s governing body. This organizational structure may include but is not limited to the utilization review committee or a quality assurance committee.
(g)the staff position functionally responsible for day-to-day program management.
(3)A health insurance issuer shall:
(a)file an annual summary report of its utilization review program activities with the commissioner in the format specified by the commissioner;
(b)maintain records for a minimum of 6 years of all benefit requests, claims, and notices associated with utilization review and benefit determinations made in accordance with 33-32-211 and 33-32-212; and
(c)make the records maintained under subsection (3)(b) available, on request, for examination by covered persons, the commissioner, and appropriate federal agencies.