37.108.310    INDEPENDENT REVIEW OF HEALTH CARE DECISIONS: NOTICE OF ADVERSE DETERMINATION AND INDEPENDENT REVIEW RIGHTS

(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.

History: Sec. 33-37-105, MCA; IMP, Sec. 33-37-102, MCA; NEW, 1999 MAR p. 2880, Eff. 12/17/99; AMD, 2003 MAR p. 1662, Eff. 8/1/03.