reglab/housing_qa huggingface dataset:
MT Code § 33-31-405 (2021)
2021 Montana Code Annotated|Title 33. Insurance and Insurance Companies|Chapter 31. Health Maintenance Organizations|Part 4. Supervision, Rehabilitation, and Liquidation|33-31-405. Penalties and enforcement

  33-31-405. Penalties and enforcement. (1) The commissioner may, in addition to suspension or revocation of a certificate of authority under 33-31-402, after notice and hearing, impose an administrative penalty in an amount not less than $500 or more than $10,000 if the commissioner gives reasonable notice in writing of the intent to levy the penalty and the health maintenance organization has a reasonable time within which to remedy the defect in its operations that gave rise to the penalty citation.   (2) If the commissioner has cause to believe that a violation of this chapter has occurred or is threatened, the commissioner may:   (a) give notice to the health maintenance organization and to the representatives or other persons who appear to be involved in the suspected violation;   (b) arrange a conference with the alleged violators or their authorized representatives to attempt to ascertain the facts relating to the suspected violation; and   (c) if it appears that a violation has occurred or is threatened, arrive at an adequate and effective means of correcting or preventing the violation.   (3) (a) The commissioner may issue an order directing a health maintenance organization or its representative to cease and desist from engaging in an act or practice in violation of this chapter.   (b) Within 15 days after service of the cease and desist order, the respondent may request a hearing to determine whether acts or practices in violation of this chapter have occurred. The hearing must be conducted pursuant to Title 2, chapter 4, part 6, and judicial review must be available as provided by Title 2, chapter 4, part 7.   (4) If a health maintenance organization violates a provision of this chapter and the commissioner elects not to issue a cease and desist order or if the respondent does not comply with a cease and desist order issued pursuant to subsection (3), the commissioner may institute a proceeding to obtain injunctive or other appropriate relief in the district court of Lewis and Clark County.   History: En. Sec. 23, Ch. 457, L. 1987; amd. Sec. 9, Ch. 437, L. 1991; amd. Sec. 1255, Ch. 56, L. 2009.
MT Code § 33-32-101 (2021)
2021 Montana Code Annotated|Title 33. Insurance and Insurance Companies|Chapter 32. Health Utilization Review|Part 1. General Provisions|33-32-101. Purpose

  33-32-101. Purpose. The legislature finds and declares that it is the purpose of this chapter to:   (1) promote the delivery of quality health care in a cost-effective manner;   (2) foster greater coordination between health care providers, third-party payors, and others who conduct utilization review activities;   (3) ensure timely access to health care services;   (4) preserve the integrity of the health care provider and patient relationship;   (5) protect patients, employers, and health care providers by:   (a) ensuring that utilization review activities result in informed decisions on the appropriateness of medical care made by those best qualified to be involved in the utilization review process; and   (b) establishing the use of written clinical criteria for utilization review programs and reviews by appropriate health care providers to ensure a fair and transparent process for patients; and   (6) establish written standards and clinical criteria for the structure and operation of utilization review and benefit determination processes designed to facilitate ongoing assessment and management of health care services.   History: En. Sec. 1, Ch. 665, L. 1991; amd. Sec. 34, Ch. 428, L. 2015; amd. Sec. 1, Ch. 470, L. 2019.
MT Code § 33-32-103 (2021)
2021 Montana Code Annotated|Title 33. Insurance and Insurance Companies|Chapter 32. Health Utilization Review|Part 1. General Provisions|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:   (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.   History: En. Sec. 3, Ch. 665, L. 1991; amd. Sec. 5, Ch. 561, L. 1993; amd. Sec. 36, Ch. 428, L. 2015; amd. Sec. 39, Ch. 151, L. 2017.
MT Code § 33-32-104 (2021)
2021 Montana Code Annotated|Title 33. Insurance and Insurance Companies|Chapter 32. Health Utilization Review|Part 1. General Provisions|33-32-104. Preemption by federal law

  33-32-104. Preemption by federal law. If any provision of this chapter is preempted by federal law or regulations as applied to any specific health care service, then the provision of this chapter that is preempted by federal law or regulations does not apply to that health care service but only to the extent of the preemption.   History: En. Sec. 8, Ch. 665, L. 1991; amd. Sec. 37, Ch. 428, L. 2015.
MT Code § 33-32-105 (2021)
2021 Montana Code Annotated|Title 33. Insurance and Insurance Companies|Chapter 32. Health Utilization Review|Part 1. General Provisions|33-32-105. Application -- exemptions

  33-32-105. Application -- exemptions. (1) Except as provided in subsections (2) and (3), the provisions of this chapter apply to:   (a) a health insurance issuer that offers a health plan and provides or performs utilization review services;   (b) any designee of the health insurance issuer or utilization review organization that performs utilization review functions on the health insurance issuer's behalf; and   (c) a health insurance issuer or its designated utilization review organization that provides or performs prospective review or retrospective review benefit determinations.   (2) A general in-house utilization review for a health care provider, including an in-house utilization review that is conducted by or for a long-term care facility and that is required by regulations for medicare or medicaid, is exempt from the provisions of this chapter as long as the review does not directly result in the approval or denial of payment for health care services for a particular case.   (3) A peer review procedure conducted by a professional society or association of providers is exempt from the provisions of this chapter.   History: En. Sec. 9, Ch. 665, L. 1991; amd. Sec. 38, Ch. 428, L. 2015.
MT Code § 33-32-106 (2021)
2021 Montana Code Annotated|Title 33. Insurance and Insurance Companies|Chapter 32. Health Utilization Review|Part 1. General Provisions|33-32-106. Disclosure of utilization review requirements -- drug benefit information

  33-32-106. Disclosure of utilization review requirements -- drug benefit information. (1) A utilization review organization shall make its current utilization review plan prepared pursuant to 33-32-103, including clinical review criteria, standards, procedures, requirements, and restrictions, readily accessible on its website to covered persons, prospective covered persons, and health care providers. The utilization review plan must be described in detail and in easily understandable language.   (2) If a utilization review organization intends to implement a new or amended utilization review plan, including any new or amended clinical review criteria, standards, procedures, requirements, or restrictions, the entity may not implement the change until it has:   (a) notified health care providers in writing of the new or amended utilization review plan, including any new or amended clinical review criteria, standards, procedures, requirements, or restrictions, no less than 60 days before the new or amended plan is to be implemented; and   (b) updated its website to reflect the new or amended utilization review plan, including any new or amended clinical review criteria, standards, procedures, requirements, or restrictions, to make the information accessible to covered persons, prospective covered persons, and health care providers.   (3) A health insurance issuer or utilization review organization, as applicable, shall display on its public website current prescription drug benefit information, including formulary lists of each prescription drug covered under the health insurance issuer's plan.   History: En. Sec. 6, Ch. 470, L. 2019.
MT Code § 33-32-107 (2021)
2021 Montana Code Annotated|Title 33. Insurance and Insurance Companies|Chapter 32. Health Utilization Review|Part 1. General Provisions|33-32-107. Length of prior authorization

  33-32-107. Length of prior authorization. A certification by a utilization review organization approving health care services is valid for at least 3 months from the date the health care provider receives the certification unless the covered person loses coverage under the applicable health plan or health insurance coverage.   History: En. Sec. 7, Ch. 470, L. 2019.
MT Code § 33-32-201 (2021)
2021 Montana Code Annotated|Title 33. Insurance and Insurance Companies|Chapter 32. Health Utilization Review|Part 2. Utilization Review -- Conduct|33-32-201. Repealed

  33-32-201. Repealed. Sec. 40, Ch. 428, L. 2015.   History: En. Sec. 4, Ch. 665, L. 1991; amd. Sec. 1, Ch. 378, L. 1993.
MT Code § 33-32-202 (2021)
2021 Montana Code Annotated|Title 33. Insurance and Insurance Companies|Chapter 32. Health Utilization Review|Part 2. Utilization Review -- Conduct|33-32-202. Commissioner not to approve or disapprove plans

  33-32-202. Commissioner not to approve or disapprove plans. Nothing in this chapter may be construed as authorizing the commissioner to approve or disapprove a utilization review plan required in 33-32-103.   History: En. Sec. 5, Ch. 665, L. 1991.
MT Code § 33-32-203 (2021)
2021 Montana Code Annotated|Title 33. Insurance and Insurance Companies|Chapter 32. Health Utilization Review|Part 2. Utilization Review -- Conduct|33-32-203. Repealed

  33-32-203. Repealed. Sec. 40, Ch. 428, L. 2015.   History: En. Sec. 6, Ch. 665, L. 1991.
MT Code § 33-32-204 (2021)
2021 Montana Code Annotated|Title 33. Insurance and Insurance Companies|Chapter 32. Health Utilization Review|Part 2. Utilization Review -- Conduct|33-32-204. Repealed

  33-32-204. Repealed. Sec. 40, Ch. 428, L. 2015.   History: En. Sec. 7, Ch. 665, L. 1991.
MT Code § 33-32-205 (2021)
2021 Montana Code Annotated|Title 33. Insurance and Insurance Companies|Chapter 32. Health Utilization Review|Part 2. Utilization Review -- Conduct|33-32-205. Corporate oversight of utilization review program

  33-32-205. Corporate oversight of utilization review program. A health insurance issuer is responsible for:   (1) monitoring all utilization review activities carried out by or on behalf of the health insurance issuer;   (2) ensuring that all requirements of this part and rules adopted pursuant to this part are met; and   (3) ensuring that appropriate personnel have operational responsibility for the conduct of the health insurance issuer's utilization review program.   History: En. Sec. 1, Ch. 428, L. 2015.
MT Code § 33-32-206 (2021)
2021 Montana Code Annotated|Title 33. Insurance and Insurance Companies|Chapter 32. Health Utilization Review|Part 2. Utilization Review -- Conduct|33-32-206. Responsibility for contracted services

  33-32-206. Responsibility for contracted services. Whenever a health insurance issuer contracts with a utilization review organization or other entity to perform the utilization review functions required by this part or rules adopted pursuant to this part, the commissioner shall hold the health insurance issuer responsible for monitoring the activities of the utilization review organization or the entity with which the health insurance issuer has contracted and for ensuring that the requirements of this part are met.   History: En. Sec. 2, Ch. 428, L. 2015.
MT Code § 33-32-207 (2021)
2021 Montana Code Annotated|Title 33. Insurance and Insurance Companies|Chapter 32. Health Utilization Review|Part 2. Utilization Review -- Conduct|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:   (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.   History: En. Sec. 3, Ch. 428, L. 2015.
MT Code § 33-32-209 (2021)
2021 Montana Code Annotated|Title 33. Insurance and Insurance Companies|Chapter 32. Health Utilization Review|Part 2. Utilization Review -- Conduct|33-32-209. and 33-32-210 reserved

  33-32-209 and 33-32-210 reserved.
MT Code § 33-32-213 (2021)
2021 Montana Code Annotated|Title 33. Insurance and Insurance Companies|Chapter 32. Health Utilization Review|Part 2. Utilization Review -- Conduct|33-32-213. and 33-32-214 reserved

  33-32-213 and 33-32-214 reserved.
MT Code § 33-32-216 (2021)
2021 Montana Code Annotated|Title 33. Insurance and Insurance Companies|Chapter 32. Health Utilization Review|Part 2. Utilization Review -- Conduct|33-32-216. Confidentiality

  33-32-216. Confidentiality. A health insurance issuer and its designee shall comply with all applicable state and federal laws establishing confidentiality and reporting requirements with regard to its utilization review program, including the provisions of Title 33, chapter 19, and 45 CFR, parts 160 and 164.   History: En. Sec. 8, Ch. 428, L. 2015.
MT Code § 33-32-217 (2021)
2021 Montana Code Annotated|Title 33. Insurance and Insurance Companies|Chapter 32. Health Utilization Review|Part 2. Utilization Review -- Conduct|33-32-217. Disclosure

  33-32-217. Disclosure. (1) In the certificate of coverage and member handbook provided to covered persons, a health insurance issuer shall include a clear and comprehensive description of its utilization review procedures, including the procedures for obtaining review of adverse determinations, and a statement of the rights and responsibilities of covered persons with respect to those procedures.   (2) In the outline of coverage provided to covered persons, a health insurance issuer shall include a statement indicating the section of the member handbook containing the information required in subsection (1).   (3) A health insurance issuer shall print on its membership cards a toll-free telephone number to call for utilization review and benefit determinations.   History: En. Sec. 9, Ch. 428, L. 2015.
MT Code § 33-32-301 (2021)
2021 Montana Code Annotated|Title 33. Insurance and Insurance Companies|Chapter 32. Health Utilization Review|Part 3. Grievance Procedures|33-32-301. Short title

  33-32-301. Short title. The provisions of Title 33, chapter 32, parts 3 and 4, may be cited as the "Health Insurance Issuer Grievance Procedures and External Review Act".   History: En. Sec. 10, Ch. 428, L. 2015.
MT Code § 33-32-302 (2021)
2021 Montana Code Annotated|Title 33. Insurance and Insurance Companies|Chapter 32. Health Utilization Review|Part 3. Grievance Procedures|33-32-302. Applicability and scope

  33-32-302. Applicability and scope. (1) Except as provided in subsection (2), the provisions of Title 33, chapter 32, parts 3 and 4, apply to all health insurance issuers.   (2) The provisions of Title 33, chapter 32, parts 3 and 4, do not apply to:   (a) a policy or certificate that provides coverage only for a specified disease or specified accident, accident-only coverage, credit insurance as described in 33-1-206, dental, disability income, or hospital indemnity insurance, long-term care insurance as defined in 33-22-1107, vision care insurance, or any other limited supplemental benefit;   (b) a medicare supplement policy as defined in 33-22-903;   (c) coverage under a plan through medicare or medicaid or any coverage issued under Title 10, chapter 55, of the United States Code and any coverage issued as supplemental to that coverage; or   (d) any coverage issued as supplemental to liability insurance, workers' compensation or similar insurance, automobile medical payment insurance, or any insurance under which benefits are payable with or without regard to fault, whether written on a group blanket basis or an individual basis.   History: En. Sec. 11, Ch. 428, L. 2015.
MT Code § 33-32-303 (2021)
2021 Montana Code Annotated|Title 33. Insurance and Insurance Companies|Chapter 32. Health Utilization Review|Part 3. Grievance Procedures|33-32-303. Purpose

  33-32-303. Purpose. The purpose of this part is to provide standards for the establishment and maintenance of procedures by health insurance issuers to ensure that covered persons have the opportunity for the appropriate resolution of grievances.   History: En. Sec. 12, Ch. 428, L. 2015.
MT Code § 33-32-304 (2021)
2021 Montana Code Annotated|Title 33. Insurance and Insurance Companies|Chapter 32. Health Utilization Review|Part 3. Grievance Procedures|33-32-304. and 33-32-305 reserved

  33-32-304 and 33-32-305 reserved.
MT Code § 33-32-306 (2021)
2021 Montana Code Annotated|Title 33. Insurance and Insurance Companies|Chapter 32. Health Utilization Review|Part 3. Grievance Procedures|33-32-306. Grievance reporting and recordkeeping requirements -- definition

  33-32-306. Grievance reporting and recordkeeping requirements -- definition. (1) (a) A health insurance issuer shall maintain within a register all written records that document grievances received during a calendar year, including the notices and claims associated with the grievances.   (b) For the purposes of this section, "register" means the written record of grievances received by a health insurance issuer that includes the notices and claims associated with the grievances as required by this section.   (2) Retention of the records in the register must be as provided in subsection (6), except that a health insurance issuer shall maintain for at least 6 years those records specified by the commissioner by rule.   (3) A health insurance issuer shall:   (a) maintain the records in a manner that is reasonably clear and accessible to the commissioner; and   (b) make the records available for examination, on request, by covered persons, the commissioner, and any appropriate federal oversight agency.   (4) A request for a review of a grievance involving an adverse determination must be processed in compliance with 33-32-308 and must be included in the register.   (5) For each grievance, the register must contain, at a minimum, the following information:   (a) a general description of the reason for the grievance;   (b) the date received;   (c) the date of each review or, if applicable, review meeting;   (d) a report on the resolution of the grievance, if applicable;   (e) the date of the resolution, if applicable; and   (f) the name of the covered person for whom the grievance was filed.   (6) Subject to the provisions of subsection (2), a health insurance issuer shall retain the register compiled in a calendar year for 3 years or until the commissioner has adopted a final report of an examination that contains a review of the register for that calendar year, whichever is longer.   (7) (a) At least annually, a health insurance issuer shall submit to the commissioner a report in the format specified by the commissioner.   (b) The report must include for each type of health plan offered by the health insurance issuer:   (i) the certificate of compliance required by 33-32-307(4)(b);   (ii) the number of covered persons;   (iii) the total number of grievances;   (iv) the number of grievances resolved, if applicable, and their resolution;   (v) the number of grievances referred to an alternative dispute resolution procedure or resulting in litigation; and   (vi) a synopsis of actions taken or being taken to correct problems that have been identified.   History: En. Sec. 13, Ch. 428, L. 2015; amd. Sec. 11, Ch. 62, L. 2019.
MT Code § 33-32-401 (2021)
2021 Montana Code Annotated|Title 33. Insurance and Insurance Companies|Chapter 32. Health Utilization Review|Part 4. External Review|33-32-401. Purpose

  33-32-401. Purpose. The purpose of this part is to provide uniform standards for the establishment and maintenance of external review procedures to ensure that covered persons have the opportunity for an independent review of an adverse determination or a final adverse determination.   History: En. Sec. 17, Ch. 428, L. 2015.
MT Code § 33-32-404 (2021)
2021 Montana Code Annotated|Title 33. Insurance and Insurance Companies|Chapter 32. Health Utilization Review|Part 4. External Review|33-32-404. Request for external review

  33-32-404. Request for external review. (1) Except for a request for an expedited external review provided for in 33-32-411, all requests for an external review must be made in writing to the health insurance issuer.   (2) A request for expedited external review may be made by telephone or in another expeditious manner.   (3) The commissioner may prescribe the form and content of external review requests submitted under this section.   (4) A covered person or, if applicable, the covered person's authorized representative may make a request for an external review of an adverse determination or a final adverse determination.   History: En. Sec. 20, Ch. 428, L. 2015.