Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.108 - MANAGED CARE QUALITY ASSURANCE › Subchapter 37.108.3 - Independent Review of Health Care Decisions › Rule 37.108.305 - INDEPENDENT REVIEW OF HEALTH CARE DECISIONS: PEER REVIEW PROCESS

Current through Register Vol. 13, July 5, 2024
(1) A health carrier or managed care entity
				and an enrollee may agree on a peer to conduct an independent review, as
				specified in these rules, of any adverse determination made by the health
				carrier or managed care entity. If the health carrier or managed care entity
				and the enrollee are unable to agree on a peer to conduct the independent
				review, then the health carrier or managed care entity shall forward the case
				file to the independent review organization designated by the
				department.
(2) The peer or the
				independent review organization designated by the department shall ensure that
				the case file contains the information listed in
				33-37-102(2) (a) through (2)
				(d), MCA, and that it otherwise is eligible
				for independent review.
(3) In the
				case of routine health care decisions, the peer or independent review
				organization shall notify the health carrier or managed care entity, the
				enrollee, and the health care provider of its decision within 30 calendar days
				after receiving the case file. The notification shall include a statement of
				the basis for the decision and shall list the evidence the peer or independent
				review organization considered in making the decision. If the peer or
				independent review organization requires additional time to complete its
				review, it shall request an extension in writing from the department. The
				request for extension shall include the reasons for the request and state the
				specific time the review is expected to be completed.
(4) In the case of expedited review, the
				enrollee's health care provider must certify in writing, facsimile, or by
				electronic mail the need for the expedited review. Within 72 hours from the
				date the request for expedited review is received, the peer or independent
				review organization shall notify the health carrier or managed care entity, the
				enrollee, and the health care provider of its decision. The notification shall
				include a statement of the basis for the decision and shall list the evidence
				the peer or independent review organization considered in making the
				decision.
(5) A peer or independent
				review organization may not review any adverse determination in which the peer
				or independent review organization has an interest in the outcome. The peer or
				independent review organization must notify the health carrier or managed care
				entity and enrollee if there is a potential conflict of interest. The peer or
				independent review organization may not review any adverse determination which
				involves a potential conflict of interest unless the health carrier or managed
				care entity and enrollee provide a written acknowledgment of the conflict and
				waiver.
(6) A health carrier or
				managed care entity or its agent that provides medicaid-funded or any other
				publicly funded health care-related services is exempt from this peer review
				process for adverse determinations concerning clients covered by those
				programs.
Sec.
					 33-37-105,
					 MCA; IMP, Sec.
					 33-37-102 and
					 33-37-103,
					 MCA;