This text of Montana § 33-32-103 (Utilization Review Plan) is published on Counsel Stack Legal Research, covering Montana primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.
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.