This bill seeks to revise Montana's utilization review laws by introducing new provisions and amending existing definitions to enhance the efficiency and fairness of the review process. Key changes include exemptions from utilization review for certain health care providers based on their past approval rates, a requirement for utilization review organizations to honor service certifications for at least the first 12 months when a covered person changes health plans, and stipulations that only licensed physicians can make adverse determinations or review grievances. Additionally, if a utilization review organization fails to meet deadlines, the certification for any health care service under review will be automatically deemed approved. The definition of "prospective review" is also expanded to include medical necessity reviews and prior authorizations.

Further amendments include the requirement for utilization review organizations to make their review plans and criteria easily accessible online, as well as to provide detailed statistics on certifications and denials. The bill extends the validity of certifications for health care services from 3 months to 12 months and allows for certifications related to chronic conditions to remain valid for the duration of treatment. It also mandates that health insurance issuers accept certification requests for pharmacy benefits exclusively through secure electronic transmissions by January 1, 2025, and emphasizes the need for oversight of delegated utilization review activities to ensure impartiality. Overall, these changes aim to improve transparency, accountability, and continuity of care within the health care system.

Statutes affected:
Introduced: 33-32-102, 33-32-106, 33-32-107, 33-32-208