Montana Code 33-32-421. External review reporting requirements
33-32-421. External review reporting requirements. (1) An independent review organization assigned pursuant to 33-32-410, 33-32-411, or 33-32-412 to conduct an external review shall maintain written records in the aggregate by state and by health insurance issuer on all requests for external reviews for which the independent review organization conducted an external review during the calendar year.
Terms Used In Montana Code 33-32-421
- 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
- 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
- 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
- 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
(2)Each independent review organization required to maintain written records as provided in subsection (1) shall submit to the commissioner, at least annually by March 1, a report in the format specified by the commissioner.
(3)The report must include, aggregated by state and by health insurance issuer:
(a)the total number of requests for external review;
(b)the number of requests for external review resolved and, of those resolved, the number resolved upholding the adverse determination or final adverse determination and the number resolved reversing the adverse determination or final adverse determination;
(c)the average length of time for resolution;
(d)a summary of the types of coverages or cases for which an external review was sought, provided in the format required by the commissioner;
(e)the number of external reviews that were terminated pursuant to 33-32-410(17) or 33-32-412(15) as the result of a reconsideration by the health insurance issuer of its adverse determination or final adverse determination after the receipt of additional information from the covered person or, if applicable, the covered person‘s authorized representative; and
(f)any other information the commissioner may request or require.
(4)The independent review organization shall retain the written records required pursuant to subsection (1) for at least 6 years.
(5)Each health insurance issuer shall maintain in the aggregate for each type of health plan offered by the health insurance issuer written records on all requests for external review for which the health insurance issuer received notice pursuant to Title 33, chapter 32, parts 2 through 4.
(6)Each health insurance issuer required to maintain written records on all requests for external review pursuant to subsection (5) shall submit to the commissioner, at least annually by March 1, a report in the format specified by the commissioner.
(7)The report must include in the aggregate by state and by type of health plan:
(a)the total number of requests for external review;
(b)the number of requests determined eligible for a full external review based on the total number of requests for external review reported under subsection (7)(a);
(c)the number of requests for external review resolved and, of those resolved, the number resolved upholding the adverse determination or final adverse determination and the number resolved reversing the adverse determination or final adverse determination;
(d)the average length of time for resolution;
(e)a summary of the types of coverage or cases for which an external review was sought, as provided in the format required by the department;
(f)the number of external reviews that were terminated as the result of a reconsideration by the health carrier of its adverse determination or final adverse determination after the receipt of additional information from the covered person or, if applicable, the covered person’s authorized representative; and
(g)any other information the commissioner may request or require.
(8)The health insurance issuer shall retain the written records required pursuant to subsection (5) for at least 6 years.