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 37.108.315 - INDEPENDENT REVIEW OF HEALTH CARE DECISIONS: INTERNAL APPEALS PROCESS
Current through Register Vol. 6, March 22, 2024
(1) If a health carrier or managed care entity has an internal appeals process in place, the internal appeals process provided by the health carrier or managed care entity must be exhausted before the enrollee or the enrollee's authorized representative can submit a decision for independent review, unless:
(2) The health carrier or managed care entity shall maintain written records of all requests for appeal and shall retain all related data for a period of three years unless a claim, audit, or litigation involving the records and data is pending, in which case the records and data must be retained until the claim, audit, or litigation is finally resolved, or for three years, whichever is longer.
(3) The peer or independent review organization shall retain all records and data generated by the peer or independent review organization for the purposes of completing the review for no less than three years, unless a claim, audit or litigation is pending, in which case the records or data shall be retained until the claim, audit or litigation is finally resolved or for three years, whichever is longer.
(4) The department shall have reasonable access to the records and data for quality assurance purposes, to perform an evaluation of the independent review process, or for any other lawful purpose of the department.
Sec. 33-37-105, MCA; IMP, Sec. 33-37-102, MCA;