Montana § 33-32-103 Utilization Review Plan

Montana Statutes

§ 33-32-103 — Utilization Review Plan

Montana·Title 33 INSURANCE AND INSURANCE COMPANIES·Ch. 32 HEALTH UTILIZATION REVIEW·Part 1 General Provisions

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

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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.

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