The bill revises laws related to health utilization review by mandating that only a physician licensed in the state can make or review adverse determinations or grievances for utilization review organizations. It specifies that the physician must have a current, valid nonrestricted license and a specialty relevant to the condition being reviewed. Additionally, the physician must operate under the clinical direction of a medical director from the utilization review organization, who is also required to be a licensed physician. The bill also outlines qualifications for physicians reviewing grievances, ensuring they have relevant experience and are not involved in the initial adverse determination.

Furthermore, the bill amends Section 33-32-221 of the Montana Code Annotated (MCA) to include new provisions regarding prior authorization requirements for prescription drugs. It prohibits health insurance issuers from performing prior authorization on certain drugs, including those prescribed for substance use disorders, provided they are FDA-approved and within labeled dosages. The bill also removes the automatic approval clause for health care services under review if a health insurance issuer or utilization review organization fails to comply with requirements, emphasizing the need for physician involvement in adverse determinations related to prescription drugs.

Statutes affected:
SB0446_X(1): 33-32-221
SB0446_X(2): 33-32-221
SB0446_X(3): 33-32-221
SB0446_X(4): 33-32-221
SB0446_X(5): 33-32-221
SB0446_X(6): 33-32-221
SB0446_X(7): 33-32-221
SB0446_X(8): 33-32-221
SB0446_X: 33-32-221