Montana § 33-32-103 - Utilization Review Plan

§ 33-32-103. Utilization Review Plan

Utilization review plan. An entity covered under the provisions of this chapter may not conduct a utilization review of health care services provided or to be provided to a patient covered under a contract or plan for health care services issued in this state unless that entity, at all times, maintains and can provide at the commissioner's request a current utilization review plan that includes: (1) a description of review criteria, standards, and procedures to be used in evaluating proposed or delivered health care services that, to the extent possible, must: (a) be based on nationally recognized criteria, standards, and procedures; (b) reflect community standards of care, except that a utilization review plan for health care services under the medicaid program provided for in Title 53 need not reflect community standards of care; (c) ensure quality of care; and (d) ensure access to needed health care services; (2) policies and procedures to ensure that a representative of the entity conducting the utilization review is reasonably accessible to patients and health care providers at all times; (3) policies and procedures to ensure compliance with all applicable state and federal laws to protect the confidentiality of individual medical records; (4) a copy of the materials designed to inform applicable patients and health care providers of the requirements of the utilization review plan; and (5) any other information that may be required by the commissioner that is necessary to implement this chapter.