Administrative Rules of Montana › Department 24 - LABOR AND INDUSTRY › Chapter 24.29 - WORKERS' COMPENSATION AND OCCUPATIONAL DISEASE › Subchapter 24.29.16 - Utilization and Treatment Guidelines › Rule 24.29.1641 - INDEPENDENT MEDICAL REVIEW PROCESS

Current through Register Vol. 13, July 5, 2024
(1) An
				interested party who has requested and been denied authorization by the insurer
				for treatment, or an insurer, may request an independent medical review by the
				medical director designated by the department prior to mediation under
				39-71-2401,
				MCA. If the independent medical review process is requested prior to mediation,
				the mediation process shall not proceed until completion of the independent
				medical review process.
(2) The
				interested party or insurer must submit its request for review to the
				department and must notify the other party of its request for review. Upon
				notice of a request for review, the insurer must submit a copy of the request
				for prior authorization, the denial, and any other relevant medical information
				to the department. The interested party and the insurer may also submit
				additional information to the department, if the information falls within the
				categories outlined in ARM 24.29.1621. Any new information submitted to the
				department must also be submitted to the other party.
(3) The medical director will review the
				medical records of the injured worker and other information relevant to the
				denial and issue a recommendation. For purposes of this rule, the medical
				director is the specific individual designated by the department to serve as
				the medical director with respect to a given set of disputed treatments or
				procedures. The medical director may seek consultation from other providers
				with specialties as would typically manage the medical condition at issue. If a
				consultation is sought and received, that provider's recommendation is also
				subject to the provisions of this rule.
(4) The medical director shall, within five
				days of receipt of the request for review, issue a written recommendation to
				the interested party and the insurer by mail, facsimile, or e-mail, or issue a
				notice that additional information or time is required to tender a
				recommendation along with an approximate date the recommendation will be
				issued, not to exceed 14 days from the date of receipt of the review request.
				If the medical director does not issue a recommendation within 14 days, the
				request for review is deemed denied and the parties may proceed to
				mediation.
(5) The medical
				director's review and recommendation is an informal alternative dispute
				resolution process without administrative or judicial authority and is not
				binding on the parties.
(a) The medical
				director's files and records are closed to all persons but the
				parties.
(b) The medical director
				may not be called to testify in any proceeding concerning the issues discussed
				in the independent medical review process.
(c) The medical director's recommendation and
				any information contained in the recommendation that is solely from the medical
				director are not admissible as evidence in any action subsequently brought in
				any court of law.
(d) The medical
				director's recommendation, including information contained in the
				recommendation, may be considered in mediation conducted under
				39-71-2401,
				MCA.