Montana Code 33-32-212. Procedures for expedited utilization review and benefit determinations
33-32-212. Procedures for expedited utilization review and benefit determinations. (1) With respect to urgent care requests and concurrent review urgent care requests, a health insurance issuer shall establish written procedures and clinical review criteria for receiving benefit requests from covered persons or, if applicable, their authorized representatives, for conducting an expedited utilization review and making benefit determinations, and for notifying the covered persons or their authorized representatives of the expedited utilization review and benefit determinations.
Terms Used In Montana Code 33-32-212
- 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 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
- 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
- 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
- External review: describes the set of procedures provided for in Title 33, chapter 32, part 4. 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.
- 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
- 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
- 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
(2)(a) The procedures established under subsection (1) must include a requirement for the health insurance issuer to provide that, in the case of a failure by a covered person or, if applicable, the covered person‘s authorized representative to follow the health insurance issuer’s procedures for filing an urgent care request, the covered person or the covered person’s authorized representative must be notified of the failure and the proper procedures to be followed for filing the request.
(b)The notice required under subsection (2)(a):
(i)must be provided to the covered person or, if applicable, the covered person’s authorized representative not later than 24 hours after receipt of the request; and
(ii)may be made orally, unless the covered person or, if applicable, the covered person’s authorized representative requests the notice in writing or electronically.
(c)To qualify for the provisions of this subsection (2) related to a failed filing procedure, the communication must:
(i)be sent by a covered person or, if applicable, the covered person’s authorized representative and received by a person or organizational unit of the health insurance issuer responsible for handling benefit matters; and
(ii)contain a reference to a specific covered person, a specific medical condition or symptom, and a specific health care service, treatment, or health care provider for which approval is being requested.
(3)(a) For an urgent care request, unless the covered person or, if applicable, the covered person’s authorized representative has failed to provide sufficient information for the health insurance issuer to determine whether or to what extent the benefits requested are covered benefits or payable under the health insurance issuer’s health plan, the health insurance issuer shall notify the covered person or, if applicable, the covered person’s authorized representative as soon as possible, taking into account the medical condition of the covered person, but no later than 48 hours after the receipt of the request by the health insurance issuer.
(b)With respect to the request, the health insurance issuer shall state in the notification whether or not the determination is an adverse determination. If the health insurance issuer’s determination is an adverse determination, the notice must comply with the provisions of subsection (7).
(4)(a) If the covered person or, if applicable, the covered person’s authorized representative has failed to provide sufficient information for the health insurance issuer to make a determination, the health insurance issuer shall notify the covered person or, if applicable, the covered person’s authorized representative either orally or, if requested by the covered person or the covered person’s authorized representative, in writing or electronically of this failure and identify what specific information is needed. This notification must be made as soon as possible but not later than 24 hours after receipt of the request.
(b)The health insurance issuer shall, taking into account the circumstances, provide the covered person or, if applicable, the covered person’s authorized representative with a reasonable period of time to submit the necessary information. The reasonable period may not end less than 48 hours after the health insurance issuer notifies the covered person or, if applicable, the covered person’s authorized representative of the failure to submit sufficient information as provided in subsection (4)(a).
(c)A health insurance issuer shall, in cases in which more information is required as provided in subsection (4)(a), notify the covered person or, if applicable, the covered person’s authorized representative of its determination with respect to the urgent care request as soon as possible but not later than 24 hours after the earlier of:
(i)the health insurance issuer’s receipt of the requested information; or
(ii)the end of the period provided for the covered person or, if applicable, the covered person’s authorized representative to submit the requested information.
(d)If the covered person or, if applicable, the covered person’s authorized representative fails to submit the information before the end of the period of the extension, as specified in subsection (4)(b), the health insurance issuer may deny the certification of the requested benefit.
(e)If the health insurance issuer’s determination is an adverse determination, the health insurance issuer shall provide notice of the adverse determination in accordance with subsection (7).
(5)(a) For concurrent review urgent care requests involving a request by the covered person or, if applicable, the covered person’s authorized representative to extend the course of treatment beyond the initial period of time or the number of treatments, if the request is made at least 24 hours prior to the expiration of the prescribed period of time or number of treatments, the health insurance issuer shall make a determination with respect to the request and notify the covered person or, if applicable, the covered person’s authorized representative of the determination, whether it is an adverse determination or not, as soon as possible, taking into account the covered person’s medical condition, but not later than 24 hours after the health insurance issuer’s receipt of the request.
(b)If the health insurance issuer’s determination is an adverse determination, the health insurance issuer shall provide notice of the adverse determination as provided in subsection (7).
(6)For the purposes of this section, the time period within which a determination must be made begins on the date and at the time the request is filed with the health insurance issuer in accordance with the health insurance issuer’s procedures established pursuant to 33-32-207 for filing a request. The date and time the request is received by the health insurance issuer must be counted without regard to whether all of the information necessary to make the determination accompanies the filing of the request.
(7)A notification of an adverse determination under this section must, in a manner calculated to be understood by the covered person or, if applicable, the covered person’s authorized representative, set forth:
(a)information sufficient to identify the benefit request or claim involved and, if applicable, the date of service, the health care provider, and the claim amount;
(b)a statement describing the availability, upon request, of the diagnosis code and its corresponding meaning and the treatment code and its corresponding meaning. On receiving a request for a diagnosis or treatment code, the health insurance issuer shall provide the information as soon as practicable. A health insurance issuer may not consider a request for the diagnosis code and treatment information, in itself, to be a request to file a grievance for review of an adverse determination pursuant to Title 33, chapter 32, part 3, or a request for external review as outlined in Title 33, chapter 32, part 4.
(c)the specific rationale behind the adverse determination, including the denial code and its corresponding meaning, as well as a description of the health insurance issuer’s standard, if any, that was used in denying the benefit request or claim;
(d)a reference to the specific plan provisions on which the determination is based;
(e)a description of any additional material or information necessary for the covered person or, if applicable, the covered person’s authorized representative to complete the request, including an explanation of why the material or information is necessary to complete the request;
(f)a description of the health insurance issuer’s internal grievance procedures established pursuant to Title 33, chapter 32, part 3, including any time limits applicable to those procedures;
(g)a description of the health insurance issuer’s expedited grievance procedures established pursuant to Title 33, chapter 32, part 3, including any time limits applicable to those procedures;
(h)a copy of any internal rule, guideline, protocol, or other similar criteria that the health insurance issuer may have relied on to make the adverse determination. Alternatively, the health insurance issuer may provide a statement that a specific rule, guideline, protocol, or other similar criteria was relied on to make the adverse determination and that a copy of the rule, guideline, protocol, or other similar criteria will be provided free of charge to the covered person on request.
(i)an explanation of the scientific or clinical judgment for making the adverse determination if the adverse determination is based on a medical necessity or experimental or investigational treatment or similar exclusion or limit. Alternatively, the health insurance issuer may provide a statement that an explanation will be provided to the covered person free of charge on request. The explanation under this subsection (7)(i) must apply the terms of the health plan to the covered person’s medical circumstances.
(j)instructions for requesting any of the following that are applicable:
(i)a copy of the rule, guideline, protocol, or other similar criteria relied on in making the adverse determination in accordance with subsection (7)(h); or
(ii)the written statement of the scientific or clinical rationale for the adverse determination in accordance with subsection (7)(i); and
(k)a statement explaining the availability of further assistance from the commissioner’s office and the right of the covered person or, if applicable, the covered person’s authorized representative to contact the commissioner’s office at any time for assistance or, on completion of the health insurance issuer’s grievance procedure process as provided under Title 33, chapter 32, part 3, to file a civil suit in a court of competent jurisdiction. The statement must include contact information for the commissioner’s office.
(8)A health insurance issuer shall provide the notice required under this section in the manner provided in 33-32-211(9).
(9)(a) A health insurance issuer may provide the notice required under this section orally, in writing, or electronically.
(b)If notice of the adverse determination is provided orally, the health insurance issuer shall provide written or electronic notice of the adverse determination within 3 days following the oral notification.