(1) An insurer, unless otherwise provided in this rule or Montana law, may select the providers of medical services it deems necessary to meet its contractual obligations with the department.

(2) An insurer must maintain an adequate network of participating providers to serve enrollees. The insurer must notify the department when providers are deleted from the network.

(3) An insurer may establish its own enrollment and reimbursement criteria for participating providers.

(4) The insurer must offer to federally qualified health centers (FQHCs) , rural health clinics (RHCs) , Title X family planning providers, Indian health services providers, tribal health providers, urban Indian centers, migrant health centers and county public health departments terms and conditions that are at least as favorable as those offered to other contract providers, if these entities substantially meet the same access and credentialing criteria as other contract providers and only for geographic areas jointly served by the entities and the insurer.

(5) Upon written notice by the department, the insurer must exclude from providing benefits to CHIP enrollees a provider who is currently suspended or terminated by the medicaid or the medicare program in any state.

(6) Participating providers shall be licensed or certified in Montana or in the case of out-of-state providers, in the state in which they practice.

(7) Physicians, advanced practice registered nurses and physician assistants shall either have admitting privileges to at least one general or critical shortage area hospital or shall have a mechanism in place to ensure hospitalization when appropriate.

(8) An insurer may set notification and claim filing time limitations relating to the provision of care by nonparticipating providers. Failure to give notice or file claims within those time limitations, however, does not invalidate any claim if it can be shown not to have been reasonably possible to give such notice and that notice was in fact given as soon as was reasonably possible.

(9) A provider has no right to an administrative hearing with the department when the insurer has denied payment for a service provided to an enrollee.

(10) A provider, in providing benefits under contract with an insurer, is not subject to any requirements or rights provided in this rule.

(11) An insurer may not prohibit a participating provider from:

(a) discussing a treatment option with an enrollee, parent or guardian; or

(b) advocating on behalf of an enrollee within the utilization review or grievance processes established by the insurer.