Montana Code 33-32-411. Expedited external review
33-32-411. Expedited external review. (1) Except as provided in subsection (11), a covered person or, if applicable, the covered person‘s authorized representative may request an expedited external review with the health insurance issuer at the time the covered person receives:
Terms Used In Montana Code 33-32-411
- 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
- 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
- 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 insurance issuer: has the meaning provided in 33-22-140. 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
- 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
(a)an adverse determination if:
(i)the adverse determination involves a medical condition of the covered person for which the timeframe for completion of an expedited internal review of a grievance involving an adverse determination under 33-32-309 would seriously jeopardize the life or health of the covered person or would jeopardize the covered person’s ability to regain maximum function; and
(ii)the covered person or the covered person’s authorized representative has filed a request for an expedited review of a grievance involving an adverse determination as provided in 33-32-309; or
(b)a final adverse determination if:
(i)the covered person has a medical condition for which the timeframe for completion of a standard external review pursuant to 33-32-410 would seriously jeopardize the life or health of the covered person or would jeopardize the covered person’s ability to regain maximum function; or
(ii)the final adverse determination concerns an admission, availability of care, continued stay, or health care service for which the covered person received emergency services but has not been discharged from a facility.
(2)(a) On receipt of the request pursuant to subsection (1), the health insurance issuer shall immediately determine whether the request meets the review requirements under 33-32-410(2).
(b)The health insurance issuer shall immediately notify the covered person or, if applicable, the covered person’s authorized representative of its eligibility determination.
(3)(a) The commissioner may specify the form for the health insurance issuer’s notice of initial determination under subsection (2)(b) and any supporting information to be included in the notice.
(b)The notice of initial determination under subsection (2)(b) must include a statement informing the covered person or, if applicable, the covered person’s authorized representative of the right to appeal to the commissioner a health insurance issuer’s initial determination that the external review request is ineligible for review. The notice must also provide contact information for the commissioner’s office.
(4)(a) The commissioner may determine that a request is eligible for external review under 33-32-410(5) and require a referral for external review, notwithstanding a health insurance issuer’s initial determination that the request is ineligible.
(b)A determination by the commissioner under subsection (4)(a) must be based on the terms of the covered person’s health plan and all applicable provisions of Title 33, chapter 32, parts 2 through 4.
(5)(a) If the request is eligible for external review, the health insurance issuer shall immediately assign an independent review organization on a random basis, or using another method of assignment that ensures the independence and impartiality of the assignment process, from the list of approved independent review organizations compiled and maintained by the commissioner pursuant to 33-32-416 to conduct the review.
(b)In making the assignment, the health insurance issuer shall consider whether an independent review organization is qualified to conduct the particular external review based on the nature of the health care service or treatment that is the subject of the adverse determination or final adverse determination.
(c)The health insurance issuer shall also take into account other circumstances, including conflict of interest concerns pursuant to 33-32-417(4).
(6)In reaching a decision as provided in subsection (9), the assigned independent review organization is not bound by any decisions or conclusions reached during the health insurance issuer’s utilization review process, as provided in Title 33, chapter 32, part 2, or the health insurance issuer’s internal grievance process provided in Title 33, chapter 32, part 3.
(7)Upon assigning an independent review organization, the health insurance issuer or its designated utilization review organization shall provide or transmit all necessary documents and information used in making the adverse determination or final adverse determination to the assigned independent review organization electronically or by telephone or facsimile or any other available expeditious method.
(8)In addition to the documents and information provided under subsection (7), the assigned independent review organization, to the extent the information or documents are available, shall consider the documents listed in 33-32-410(19) in reaching a decision.
(9)(a) As expeditiously as the covered person’s medical condition or circumstances require but no more than 72 hours after receiving the request for an expedited external review that meets the review requirements set forth in 33-32-410(2), the assigned independent review organization shall:
(i)decide whether to uphold or reverse the adverse determination or final adverse determination; and
(ii)notify the covered person or, if applicable, the covered person’s authorized representative as well as the health insurance issuer of the decision.
(b)If the notice required under subsection (9)(a) was not provided in writing, the assigned independent review organization shall within 48 hours after the date of providing the notice:
(i)provide written confirmation of the decision to the covered person or, if applicable, the covered person’s authorized representative as well as to the health insurance issuer; and
(ii)include the information required in 33-32-410(21).
(10)On receipt of the notice regarding a decision reversing the adverse determination or final adverse determination, the health insurance issuer shall immediately approve the coverage that was the subject of the adverse determination or final adverse determination.
(11)An expedited external review may not be provided for retrospective adverse or retrospective final adverse determinations.