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 37.108.310 - INDEPENDENT REVIEW OF HEALTH CARE DECISIONS: NOTICE OF ADVERSE DETERMINATION AND INDEPENDENT REVIEW RIGHTS
Universal Citation: MT Admin Rules 37.108.310
Current through Register Vol. 6, March 22, 2024
(1) A health carrier or managed care entity shall notify an enrollee and the health care provider of any adverse determination:
(a) within 10 calendar days
from the date the decision is made if the decision involves routine medical
care; or
(b) within 48 hours from
the date the decision is made, excluding Sundays and holidays, if the decision
involves a medical care determination which qualifies for expedited
review.
(2) The notice shall:
(a) be printed in clear legible type
using a font of at least 12 point size;
(b) be written using a format and language
which can be understood by a person who has no more than an eighth grade
education;
(c) explain the reasons
for the adverse determination;
(d)
provide the enrollee with instructions on the process necessary to initiate an
appeal or independent review; and
(e) inform the enrollee that an expedited
review process is available and explain how an enrollee may initiate an
expedited review.
(3) If an internal appeal process exists, the notice shall:
(a) inform the enrollee of the enrollee's
right to appeal any adverse determination by requesting an internal review
within 180 days after the date the adverse decision is made; and
(b) notify the enrollee, once the internal
appeals process has been exhausted, of the enrollee's right to seek an
independent review of any adverse determination within 60 days after the date
the internal review decision is made.
(4) If an internal appeal process does not exist, the notice shall inform the enrollee of the enrollee's right to seek an independent review of any adverse determination within 180 days after the date the adverse decision is made.
Sec. 33-37-105, MCA; IMP, Sec. 33-37-102, MCA;
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