37.108.315    INDEPENDENT REVIEW OF HEALTH CARE DECISIONS: INTERNAL APPEALS PROCESS

(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:

(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.

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.