33-37-102. Independent review of adverse determinations. - Montana Statutes

     33-37-102. Independent review of adverse determinations. A health carrier or managed care entity or an agent of a health carrier or managed care entity, other than a health carrier or other managed care entity providing medicaid-funded services or any other publicly funded health care-related services authorized under Title 50, 52, or 53, shall:
     (1) permit any party whose appeal of an adverse determination is denied by the health carrier, the managed care entity, or the agent of the health carrier or managed care entity to seek independent review of that determination by a peer or, if the health carrier or managed care entity does not maintain an appeals process, permit any party receiving an adverse determination to seek independent review of that determination;
     (2) provide to the appropriate peer no later than the third business day after the date that the health carrier, the managed care entity, or the agent of the health carrier or managed care entity receives a request for review a copy of:
     (a) any medical records of the enrollee that are relevant to the review. Confidential information in the custody of the health carrier, the managed care entity, or the agent of the health carrier or managed care entity may be provided to a peer.
     (b) any documents used by the health carrier, the managed care entity, or the agent of the health carrier or managed care entity in making the determination to be reviewed by the peer;
     (c) any documentation and written information submitted to the health carrier, the managed care entity, or the agent of the health carrier or managed care entity in support of the appeal; and
     (d) a list of each health care provider who has provided care to the enrollee and who may have medical records relevant to the appeal;
     (3) accept and comply with the findings made by a peer conducting the independent review concerning an adverse determination, a determination as to whether the services were appropriate and medically necessary, or a health care treatment decision; and
     (4) pay for the reasonable costs of the independent review.

     History: En. Sec. 2, Ch. 482, L. 1999.