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

(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.