This rule has been transferred.

This rule has been transferred.

This rule has been transferred.

This rule has been transferred.

This rule has been transferred.

This rule has been transferred.

This rule has been transferred.

This rule has been transferred.

This rule has been transferred.

This rule has been transferred.

This rule has been transferred.

This rule has been transferred.

This rule has been transferred.

This rule has been transferred.

This rule has been transferred.

This rule has been transferred.

This rule has been transferred.

This rule has been transferred.

This rule has been transferred.

This rule has been transferred.

This rule has been transferred.

(1) "Expedited review" means an accelerated appeal of an adverse determination made by a health carrier or managed care entity involving an enrollee with urgent medical needs whose life or health would be seriously threatened by the delay of a standard appeals process.

(2) "Independent review organization" means a network of peers conducting an independent review of an adverse determination made by a health carrier or managed care entity.

(3) "Internal appeals process" means a process established by a health carrier or managed care entity by which a party affected by an adverse determination made by a health carrier or managed care entity may appeal the adverse decision within the deciding agency.

(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.

(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.

(a) the internal appeals process is not completed within 60 calendar days from the date the request for appeal is received, in which case the internal appeals process will be interrupted and the case forwarded for independent review; or

(b) the health care treatment decision results in a serious threat to the health or threatens the life of the enrollee, in which case upon certification by the health care provider as defined in (1) (b) (i) , the internal appeals process will be bypassed and the matter shall immediately be submitted for expedited review.

(i) If the enrollee's health care provider determines that the adverse determination involves a condition which seriously threatens the life or health of the enrollee, the enrollee's health care provider shall certify in writing, facsimile or by electronic mail that the life or health of the enrollee would be seriously threatened by the delay of an internal appeals process.

(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.

This rule has been transferred.

This rule has been transferred.

This rule has been transferred.

This rule has been transferred.

This rule has been transferred.

This rule has been transferred.

This rule has been transferred.

This rule has been transferred.

This rule has been transferred.

This rule has been transferred.

This rule has been transferred.