24.29.1641    INDEPENDENT MEDICAL REVIEW PROCESS

(1) An interested party who has requested and been denied authorization by the insurer for treatment, or an insurer, may request an independent medical review by the medical director designated by the department prior to mediation under 39-71-2401, MCA. If the independent medical review process is requested prior to mediation, the mediation process shall not proceed until completion of the independent medical review process.

(2) The interested party or insurer must submit its request for review to the department and must notify the other party of its request for review. Upon notice of a request for review, the insurer must submit a copy of the request for prior authorization, the denial, and any other relevant medical information to the department. The interested party and the insurer may also submit additional information to the department, if the information falls within the categories outlined in ARM 24.29.1621. Any new information submitted to the department must also be submitted to the other party.

(3) The medical director will review the medical records of the injured worker and other information relevant to the denial and issue a recommendation. For purposes of this rule, the medical director is the specific individual designated by the department to serve as the medical director with respect to a given set of disputed treatments or procedures. The medical director may seek consultation from other providers with specialties as would typically manage the medical condition at issue. If a consultation is sought and received, that provider's recommendation is also subject to the provisions of this rule.

(4) The medical director shall, within five days of receipt of the request for review, issue a written recommendation to the interested party and the insurer by mail, facsimile, or e-mail, or issue a notice that additional information or time is required to tender a recommendation along with an approximate date the recommendation will be issued, not to exceed 14 days from the date of receipt of the review request. If the medical director does not issue a recommendation within 14 days, the request for review is deemed denied and the parties may proceed to mediation.

(5) The medical director's review and recommendation is an informal alternative dispute resolution process without administrative or judicial authority and is not binding on the parties.

(a) The medical director's files and records are closed to all persons but the parties.

(b) The medical director may not be called to testify in any proceeding concerning the issues discussed in the independent medical review process.

(c) The medical director's recommendation and any information contained in the recommendation that is solely from the medical director are not admissible as evidence in any action subsequently brought in any court of law.

(d) The medical director's recommendation, including information contained in the recommendation, may be considered in mediation conducted under 39-71-2401, MCA.

(6) The insurer shall, within five days of receipt of the recommendation, notify the interested party if the previously denied treatment(s) or procedure(s) is authorized based on the medical director's recommendation.

(7) If the insurer does not authorize treatment after issuance of the medical director's recommendation, the interested party may file for mediation with the department pursuant to 39-71-2401, MCA.

(8) The provisions of this rule apply to medical services provided, or proposed to be provided, on or after July 1, 2011.

(9) An expedited case review for medications is provided by ARM 24.29.1645.

 

History: 39-71-203, 39-71-704, MCA; IMP, 39-71-224, 39-71-704, 39-71-2401, MCA; NEW, 2011 MAR p. 1137, Eff. 6/24/11; TRANS from ARM 24.29.1595 and AMD, 2018 MAR p. 2531, Eff. 1/1/19.