reglab/statecodes huggingface dataset:
2023 Montana Code Annotated › Title 33. Insurance and Insurance Companies › Chapter 31. Health Maintenance Organizations › Part 2. Authorization of Health Maintenance Organizations › 33-31-223. Fiduciary responsibilities

33-31-223. Fiduciary responsibilities.
(1) Any director, officer, employee, or partner of a health maintenance organization who receives, collects, disburses, or invests funds in connection with the activities of the health maintenance organization is responsible for the funds in the manner of a fiduciary to the health maintenance organization.
(2) A health maintenance organization shall maintain in force a fidelity bond on employees and officers in an amount not less than $100,000 or such other sum as may be prescribed by the commissioner. Each bond must be written with at least a 1-year discovery period and, if written with less than a 3-year discovery period, must contain a provision that a cancellation or termination of the bond, whether by or at the request of the insured or by the underwriter, may not take effect prior to the expiration of 90 days after written notice of the cancellation or termination has been filed with the commissioner unless the commissioner approves an earlier cancellation or termination date.
History: En. Sec. 7, Ch. 457, L. 1987.
2023 Montana Code Annotated › Title 33. Insurance and Insurance Companies › Chapter 31. Health Maintenance Organizations › Part 3. Operations › 33-31-302. Information to enrollees

33-31-302. Information to enrollees.
Each authorized health maintenance organization shall provide to its enrollees 30 days' advance notice in writing of any material change in the operation of the health maintenance organization that will affect them directly.
History: En. Sec. 10, Ch. 457, L. 1987.
2023 Montana Code Annotated › Title 33. Insurance and Insurance Companies › Chapter 31. Health Maintenance Organizations › Part 3. Operations › 33-31-303. Complaint system

33-31-303. Complaint system.
(1) (a) Each authorized health maintenance organization shall establish and maintain a complaint system to provide reasonable procedures to resolve written complaints initiated by enrollees. A health maintenance organization may not use a complaint system:
(i) before the commissioner approves it; and
(ii) unless the health maintenance organization describes it in each evidence of coverage issued or delivered to an enrollee in this state.
(b) Each time the health maintenance organization denies a claim or initiates disenrollment, cancellation, or nonrenewal, it shall notify the affected enrollee of the right to file a complaint and the procedure for filing a complaint.
(c) Each health maintenance organization shall acknowledge a complaint within 10 days of receiving it.
(d) Each health maintenance organization shall retain records of all complaints for 3 years and shall develop a summary for each year that must include:
(i) a description of the procedures of the complaint system;
(ii) the total number of complaints handled through the complaint system, a compilation of causes underlying the complaints filed, the date on which each complaint was filed, the date on which each complaint was resolved, the disposition of each complaint filed, the time it took to process each complaint, and a summary of each administrative change made because of a complaint; and
(iii) the number, amount, and disposition of malpractice claims made by enrollees of the health maintenance organization that were settled during the year by the health maintenance organization.
(e) The health maintenance organization shall annually on or before March 1 file with the commissioner the summary described in subsection (1)(d) for the preceding year.
(2) The commissioner shall hold in confidence the information provided by the health maintenance organization pursuant to subsection (1)(d)(iii).
(3) The commissioner may examine a complaint system.
History: En. Sec. 11, Ch. 457, L. 1987.
2023 Montana Code Annotated › Title 33. Insurance and Insurance Companies › Chapter 31. Health Maintenance Organizations › Part 3. Operations › 33-31-304. Dual choice

33-31-304. Dual choice.
An employer in this state that offers its employees the option to enroll in a health maintenance organization and an employee benefit fund in this state that offers its members the option to enroll in a health maintenance organization may not be required to pay more for health benefits provided by the health maintenance organization than it would otherwise be required to provide by any prevailing collective bargaining agreement or other contract for the provision of health benefits to its employees, if the employer or benefits fund pays to the health maintenance organization chosen by each employee or member an amount equal to the lesser of:
(1) the amount paid on behalf of its other employees or members of health benefits; or
(2) the health maintenance organization's charge for coverage approved by the commissioner pursuant to 33-31-301.
History: En. Sec. 29, Ch. 457, L. 1987.
2023 Montana Code Annotated › Title 33. Insurance and Insurance Companies › Chapter 31. Health Maintenance Organizations › Part 3. Operations › 33-31-305. Dentist participation as provider

33-31-305. Dentist participation as provider.
A contract for dental care services through a health maintenance organization that is offered, delivered, or renewed under this chapter must allow a dentist to request participation as a provider on the same terms and conditions as those by which other dentists participate. This opportunity for participation must be offered for each contract or plan. Each contract or plan must provide at least one annual period during which a dentist may exercise this right.
History: En. Sec. 2, Ch. 265, L. 1989.
2023 Montana Code Annotated › Title 33. Insurance and Insurance Companies › Chapter 31. Health Maintenance Organizations › Part 3. Operations › 33-31-306. Point-of-service option

33-31-306. Point-of-service option.
(1) (a) A health maintenance organization that has at least 10,000 enrollees shall offer a point-of-service option benefit plan to each purchaser of a health care services agreement. The purchaser may accept or reject the addition of a point-of-service option to the health care services agreement.
(b) For the purposes of subsection (1)(a), an enrollee does not include an individual receiving medicaid services under the Montana medicaid program provided for in Title 53, chapter 6, or an individual participating in an approved medicare risk contract administered by a licensed health maintenance organization.
(2) Any difference in premium charged for the point-of-service option benefit plan compared to the premium for a standard health care services agreement may not exceed the expected cost to the insurer of benefits and expenses based on sound actuarial principles.
(3) This section may not be construed to permit a health maintenance organization to offer stand-alone indemnity insurance coverage.
History: En. Sec. 2, Ch. 165, L. 1997.
2023 Montana Code Annotated › Title 33. Insurance and Insurance Companies › Chapter 31. Health Maintenance Organizations › Part 3. Operations › 33-31-307. Affiliation periods

33-31-307. Affiliation periods.
(1) A health maintenance organization that offers health insurance coverage in connection with a group health plan and that does not impose a preexisting condition exclusion allowed by 33-22-246 or 33-22-514 with respect to any particular coverage option may impose an affiliation period for that coverage option if:
(a) the affiliation period is applied uniformly without regard to any health status-related factors; and
(b) the affiliation period does not exceed 2 months, or 3 months in the case of a late enrollee, as defined in 33-22-140.
(2) A health maintenance organization is not required to provide health care services or benefits during the affiliation period, and a premium may not be charged to the participant or beneficiary for any coverage during the affiliation period. An affiliation period begins on the enrollment date and runs concurrently with any waiting period under the plan.
(3) A health maintenance organization may use a method other than an affiliation period to address adverse selection if the method is approved by the commissioner.
(4) The definitions in 33-22-140 apply to this section.
History: En. Sec. 43, Ch. 416, L. 1997.
2023 Montana Code Annotated › Title 33. Insurance and Insurance Companies › Chapter 31. Health Maintenance Organizations › Part 3. Operations › 33-31-311. Insurance producer license required

33-31-311. Insurance producer license required.
An individual or business entity may not act as or represent to the public that the individual or business entity is an insurance producer for a health maintenance organization unless the individual or business entity is:
(1) licensed as a disability insurance producer by the commissioner pursuant to Title 33, chapter 17, parts 1, 2, 4, and 10 through 12, or licensed as an insurance producer as provided in 33-30-311; and
(2) appointed or authorized by the health maintenance organization or other health insurance issuer to sell, solicit, or negotiate health care service agreements on its behalf.
History: En. Sec. 15, Ch. 457, L. 1987; amd. Sec. 1, Ch. 713, L. 1989; amd. Sec. 153, Ch. 42, L. 1997; amd. Sec. 68, Ch. 227, L. 2001; amd. Sec. 24, Ch. 399, L. 2007; amd. Sec. 35, Ch. 271, L. 2009.
2023 Montana Code Annotated › Title 33. Insurance and Insurance Companies › Chapter 31. Health Maintenance Organizations › Part 3. Operations › 33-31-313. Premium increase restriction -- exception

33-31-313. Premium increase restriction -- exception.
(1) A health maintenance organization may not increase a premium for an individual's or an individual's group health care services agreement more frequently than once during a 12-month period unless failure to increase the premium more frequently than once during the 12-month period would:
(a) place the health maintenance organization in violation of the laws of this state; or
(b) cause the financial impairment of the health maintenance organization to the extent that further transaction of insurance by the health maintenance organization would injure or be hazardous to its enrollees or to the public.
(2) Subsection (1) does not apply to a premium increase necessitated by a state or federal law, by a court decision, by a state rule, or by a federal regulation.
History: En. Sec. 7, Ch. 413, L. 1997.
2023 Montana Code Annotated › Title 33. Insurance and Insurance Companies › Chapter 31. Health Maintenance Organizations › Part 3. Operations › 33-31-321. Disclosure standards -- health maintenance organizations

33-31-321. Disclosure standards -- health maintenance organizations.
(1) In order to provide for full and fair disclosure in the sale of disability insurance, an enrollment form or evidence of coverage may not be delivered or issued for delivery in this state by a health maintenance organization unless an outline of coverage is delivered to the applicant at the time the application is made. The outline of coverage must be filed with the commissioner as required by 33-1-501.
(2) The outline of coverage must include:
(a) a general description of the principal benefits and coverages provided by the policy;
(b) a general description of the insureds financial responsibility under the policy, including, if applicable, the amount of the deductible, the amount or percentage of copayment, and the maximum annual out-of-pocket expenses to be paid by the insured;
(c) a statement of the maximum lifetime benefit available under the policy;
(d) a statement of the estimated periodic premium to be paid by the insured;
(e) a general description of the factors or case characteristics that the insurer may consider in establishing or changing the premiums and, if applicable, in determining the insurability of the applicant; and
(f) a general description of the trend of premium increases or decreases for comparable policies issued by the insurer during the preceding 5 years, if the trend data is available.
(3) The outline of coverage may include any other information that the insurer considers relevant to the applicant's selection of an appropriate health benefit plan.
(4) An insurer or producer shall provide to an individual, upon request, an outline of coverage for any health benefit product marketed to the general public. The outline of coverage provided under this subsection may exclude the statement of the estimated periodic premium to be paid by the insured.
History: En. Sec. 7, Ch. 527, L. 1995.
2023 Montana Code Annotated › Title 33. Insurance and Insurance Companies › Chapter 31. Health Maintenance Organizations › Part 3. Operations › 33-31-322. Repealed

33-31-322. Repealed.
Sec. 35, Ch. 63, L. 2015.
History: En. Sec. 10, Ch. 527, L. 1995; amd. Sec. 31, Ch. 416, L. 1997.
2023 Montana Code Annotated › Title 33. Insurance and Insurance Companies › Chapter 31. Health Maintenance Organizations › Part 4. Supervision, Rehabilitation, and Liquidation › 33-31-401. Examination

33-31-401. Examination.
(1) The commissioner may examine the affairs of a health maintenance organization as often as is reasonably necessary to protect the interests of the people of this state. The commissioner shall make an examination at least once every 5 years. Similarly, the commissioner shall examine a health maintenance organization operated by an insurer or health service corporation as a plan at least once every 5 years. The provisions of 33-1-408 and 33-1-409 apply to examinations under this section.
(2) Each authorized health maintenance organization and provider shall submit its relevant books and records for the examinations and in every way facilitate the examinations. For the purpose of examination, the commissioner may administer oaths to and examine the officers and insurance producers of the health maintenance organization and the principals of the providers concerning their business.
(3) (a) Upon presentation of a detailed account of the charges and expenses of examinations by the commissioner, the health maintenance organization being examined shall pay to the examiner as necessarily incurred on account of the examination the actual travel expenses, a reasonable living-expense allowance, and a per diem, all at reasonable rates customary therefor and as established or adopted by the commissioner. The commissioner may present an account periodically during the course of the examination or at the termination of the examination as the commissioner considers proper. A person may not pay and an examiner may not accept any additional emolument on account of any examination.
(b) If a health maintenance organization fails to pay the charges and expenses as referred to in subsection (3)(a), the commissioner shall pay them out of the funds of the commissioner in the same manner as other disbursements of funds. The amount paid is a lien upon all of the person's assets and property in this state and may be recovered by suit by the attorney general on behalf of the state and restored to the appropriate fund.
(4) In lieu of an examination, the commissioner may accept the report of an examination made by the commissioner of another state.
History: En. Sec. 17, Ch. 457, L. 1987; amd. Sec. 7, Ch. 628, L. 1989; amd. Sec. 1, Ch. 713, L. 1989; amd. Sec. 6, Ch. 437, L. 1991; amd. Sec. 61, Ch. 472, L. 1999; amd. Sec. 69, Ch. 227, L. 2001; amd. Sec. 37, Ch. 151, L. 2017.
2023 Montana Code Annotated › Title 33. Insurance and Insurance Companies › Chapter 31. Health Maintenance Organizations › Part 4. Supervision, Rehabilitation, and Liquidation › 33-31-403. Supervision, rehabilitation, or liquidation of health maintenance organization

33-31-403. Supervision, rehabilitation, or liquidation of health maintenance organization.
(1) The supervision, rehabilitation, or liquidation of a health maintenance organization is considered to be the supervision, rehabilitation, or liquidation of an insurer and must be conducted under the supervision of the commissioner pursuant to chapter 2, part 13. The commissioner may apply for an order directing the commissioner to supervise, rehabilitate, or liquidate a health maintenance organization upon any one or more grounds set out in 33-2-1321, 33-2-1331, or 33-2-1341 or when in the commissioner's opinion the continued operation of the health maintenance organization would be hazardous either to the enrollees or to the people of this state. Enrollees have the same priority in the event of liquidation or rehabilitation as the law provides to policyholders of an insurer.
(2) A claim by a health care provider for an uncovered expenditure has the same priority as a claim by an enrollee if the provider of services agrees not to assert the claim against any enrollee of the health maintenance organization.
History: En. Sec. 19, Ch. 457, L. 1987; amd. Sec. 1253, Ch. 56, L. 2009.
2023 Montana Code Annotated › Title 33. Insurance and Insurance Companies › Chapter 31. Health Maintenance Organizations › Part 4. Supervision, Rehabilitation, and Liquidation › 33-31-404. Administrative procedures

33-31-404. Administrative procedures.
(1) When the commissioner has cause to believe that grounds for the denial of an application for a certificate of authority exist or that grounds for the suspension or revocation of a certificate of authority exist, the commissioner shall give written notice to the health maintenance organization specifically stating the grounds for denial, suspension, or revocation and fixing a time of at least 30 days after the notice for a hearing on the matter.
(2) After the hearing or upon the failure of the health maintenance organization to appear at the hearing, the commissioner shall make written findings and act as the commissioner considers advisable. The commissioner shall mail the written findings to the health maintenance organization. The action of the commissioner is subject to review by the district court having jurisdiction. The court may, in disposing of the issue before it, modify, affirm, or reverse the order of the commissioner in whole or in part.
(3) When notice and hearing are required with regard to actions taken by the commissioner under this chapter, the requirements of 33-1-314 through 33-1-316 and Title 33, chapter 1, part 7, apply, except that the formal rules of pleading and evidence must be observed. To the extent that 33-1-314 through 33-1-316 and Title 33, chapter 1, part 7, do not address the notice and hearing requirements of this chapter, the provisions of Title 2, chapter 4, parts 6 and 7, apply.
History: En. Sec. 21, Ch. 457, L. 1987; amd. Sec. 8, Ch. 437, L. 1991; amd. Sec. 1254, Ch. 56, L. 2009.
2023 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.
2023 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.
2023 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.
2023 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.
2023 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.
2023 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.
2023 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.
2023 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.
2023 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.
2023 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.
2023 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.
2023 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.
2023 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.
2023 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.
2023 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.
2023 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.
2023 Montana Code Annotated › Title 33. Insurance and Insurance Companies › Chapter 32. Health Utilization Review › Part 2. Utilization Review -- Conduct › 33-32-221. Prior authorization requirements

33-32-221. Prior authorization requirements.
(1) A health insurance issuer may not perform prior authorization on benefits for:
(a) any generic prescription drug that is not listed within any of the schedules of controlled substances found at 21 CFR 1308.11 through 21 CFR 1308.15 or the schedules of controlled substances found in Title 50, chapter 32, after a covered person has been prescribed the covered drug at the same quantity without interruption for 6 months;
(b) any prescription drug or drugs, generic or brand name, on the grounds of therapeutic duplication for the same drug if the covered person has already been subject to prior authorization on the grounds of therapeutic duplication for the same dosage of the prescription drug or drugs and coverage of the prescription drug or drugs was approved;
(c) any prescription drug, generic or brand name, solely because the dosage of the medication for the covered person has been adjusted by the prescriber of the prescription drug, as long as the dosage is within the dosage approved by the food and drug administration or is consistent with clinical dosing for the medication; or
(d) any prescription drug, generic or brand name, that is a long-acting injectable antipsychotic.
(2) Any adverse determination for a prescription drug made during prior authorization by a health insurance issuer must be made by a physician whose specialty focuses on the diagnosis and treatment of the condition for which the prescription drug was prescribed to treat, provided that prior authorization that does not result in an adverse determination does not require the involvement of a physician on the part of a health insurance issuer.
History: En. Sec. 1, Ch. 680, L. 2023.
2023 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.
2023 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.
2023 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.
2023 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.
2023 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.
2023 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.
2023 Montana Code Annotated › Title 33. Insurance and Insurance Companies › Chapter 32. Health Utilization Review › Part 4. External Review › 33-32-415. Binding nature of external review decisions

33-32-415. Binding nature of external review decisions.
(1) An external review decision is binding on:
(a) the health insurance issuer; and
(b) the covered person except to the extent that the covered person has other remedies available under applicable federal or state law.
(2) A covered person or, if applicable, the covered person's authorized representative may not file a subsequent request for external review involving the same adverse determination or final adverse determination for which the covered person has already received an external review decision pursuant to this part.
History: En. Sec. 25, Ch. 428, L. 2015.
2023 Montana Code Annotated › Title 33. Insurance and Insurance Companies › Chapter 32. Health Utilization Review › Part 4. External Review › 33-32-418. Liability limits for independent review organization

33-32-418. Liability limits for independent review organization.
(1) Except as provided in subsection (2), an independent review organization or clinical peer working on behalf of an independent review organization or an employee, agent, or contractor of an independent review organization is not liable to any person for any opinions rendered or acts or omissions performed within the scope of the organization's or person's duties under the law during or upon completion of an external review conducted pursuant to this part.
(2) The liability exemption under subsection (1) does not apply if the opinion was rendered or if the act or omission was performed in bad faith or involved gross negligence.
History: En. Sec. 28, Ch. 428, L. 2015.
2023 Montana Code Annotated › Title 33. Insurance and Insurance Companies › Chapter 32. Health Utilization Review › Part 4. External Review › 33-32-419. Fees

33-32-419. Fees.
(1) An application for approval of an independent review organization under 33-32-416 must be accompanied by a fee of $250.
(2) An application for renewal as an approved independent review organization must be accompanied by a fee of $150.
History: En. Sec. 1, Ch. 31, L. 2019.
2023 Montana Code Annotated › Title 33. Insurance and Insurance Companies › Chapter 32. Health Utilization Review › Part 4. External Review › 33-32-422. Funding of external review

33-32-422. Funding of external review.
The health insurance issuer against which a request for a standard external review or an expedited external review is filed shall pay the costs of the independent review organization for conducting the external review.
History: En. Sec. 30, Ch. 428, L. 2015.
2023 Montana Code Annotated › Title 33. Insurance and Insurance Companies › Chapter 32. Health Utilization Review › Part 4. External Review › 33-32-423. Disclosure requirements

33-32-423. Disclosure requirements.
(1) Each health insurance issuer shall include a description of the external review procedures in or attached to the policy, certificate, membership booklet, outline of coverage, or other evidence of coverage provided to covered persons.
(2) The disclosure required under subsection (1) must:
(a) be in a format prescribed by the commissioner; and
(b) include a statement that informs the covered person of the right of the covered person or, if applicable, the covered person's authorized representative to file a request for an external review of an adverse determination or final adverse determination with the health insurance issuer. The statement may explain that external review is available when the adverse determination or final adverse determination involves an issue of medical necessity, appropriateness, health care setting, level of care, or level of effectiveness. The statement must include the telephone number and address of the commissioner.
(3) In addition to the requirements under subsection (2), the statement must inform the covered person that, when filing a request for an external review, the covered person or, if applicable, the covered person's authorized representative is required to authorize the release of any medical records of the covered person that may be required to be reviewed for the purpose of reaching a decision on the external review.
History: En. Sec. 31, Ch. 428, L. 2015; amd. Sec. 44, Ch. 151, L. 2017.
2023 Montana Code Annotated › Title 33. Insurance and Insurance Companies › Chapter 33. Property and Casualty Utilization Review › Part 1. General Provisions › 33-33-101. Purpose

33-33-101. Purpose.
The legislature recognizes that property and casualty insurers providing coverage for medical expenses or liability coverage for bodily injury may need, with respect to some claims, to seek medical reviews from qualified utilization review organizations so that an insurer may use the reviews to determine its contractual obligations. This chapter establishes standards for organizations providing utilization reviews and for property and casualty insurers seeking reviews.
History: En. Sec. 1, Ch. 335, L. 2001.