24.29.1517    PRIOR AUTHORIZATION FOR CERTAIN SERVICES

(1) This rule applies to:

(a) services provided on or before June 30, 2011; and

(b) body parts not covered by the Montana Guidelines, as described in ARM 24.29.1593.

(2) When prior authorization is required, the provider must request the authorization a reasonable amount of time in advance of the time the procedure is scheduled to be performed. The request must contain enough information to allow the insurer to make an informed decision regarding authorization. The insurer may not unreasonably withhold its authorization. An insurer's denial must contain an explanation of the reasons for its denial. Reasonableness will be judged in light of the circumstances surrounding the medical procedure and the claim.

(3) If a provider makes a written request for prior authorization at least 14 days prior to the date the service is scheduled to be performed, authorization is presumed to be given by the insurer if there is no written denial sent by the insurer to the provider within 14 days of the date the written request was mailed. If the written denial is made within three days of the expiration of the 14 day response period, the insurer must also notify the provider of the denial by telephone or facsimile ("fax").

(4) If a provider makes a verbal request for prior authorization, the burden of proof for showing that authorization was granted by the insurer rests with the provider. The provider should promptly send to the insurer a written confirmation of any verbal authorization made by the insurer. Such written confirmation should refer not only to the name of the claimant, the claim number, and the procedure authorized, but also the name of the person giving the authorization and the date the authorization was given.

(5) Prior authorization is required when:

(a) the provider to whom the referral is made is a consulting specialist; or

(b) there is a request for change of treating physician; or

(c) the claimant has not been treated for the injury (or occupational disease) within the past six months; or

(d) the claimant has been identified as having reached maximum medical improvement; or

(e) any of the following is proposed:

(i) nonemergency surgery;

(ii) an MRI or CT, if the same body part has been imaged within the last 12 months;

(iii) psychological counseling, other than provided by the treating physician;

(iv) membership in a health club;

(v) any pain clinic program;

(vi) pain medication is being prescribed for a period of six months or longer;

(vii) medical equipment and supplies if over $300.00;

(viii) a permanent change from one provider's specialty practice to the specialty practice of a different provider, for treatment of the same injury. The occasional and temporary change of provider due to illness, vacation, or emergency, does not require prior authorization; or

(ix) for any other procedure that by rule specifically requires prior authorization.

(6) For any service identified in (4)(e), additional authorization is required if the duration or extent of the service is later modified because of a change in the treatment plan.

(7) Prior authorization is not required for emergency procedures.

(8) If medical services related to the injury or occupational disease are denied pursuant to this rule because a provider failed to try to obtain prior authorization, an injured worker cannot be billed for those denied medical services pursuant to 39-71-743, MCA.

(9) When an insurer denies liability for an injury or occupational disease, and the insurer then later assumes liability for a particular condition, the insurer may not deny payment for the medical services provided for that condition during the period of denial based solely on failure to obtain prior authorization.

History: 39-71-203, MCA; IMP, 39-71-704, 39-71-743, MCA; NEW, 1993 MAR p. 404, Eff. 4/1/93; AMD, 2002 MAR p. 1758, Eff. 7/1/02; AMD, 2007 MAR p. 260, Eff. 2/23/07; AMD, 2011 MAR p. 1137, Eff. 6/24/11.