6.6.3131    LONG-TERM CARE INDEPENDENT REVIEW ORGANIZATIONS

(1) The commissioner shall certify or approve a qualified long-term care insurance independent review organization, provided the organization demonstrates to the satisfaction of the commissioner that it is unbiased and that:

(a) the organization will have on staff, or contract with, a qualified and licensed health care professional in an appropriate field for determining an insured's functional or cognitive impairment (e.g., physical therapy, occupational therapy, neurology, physical medicine and rehabilitation) to conduct the review;

(b) neither the organization, nor any of its licensed health care professionals, may be related to or affiliated with, in any manner, an entity that previously provided medical care to the insured;

(c) the organization will utilize a licensed health care professional who is not an employee of the insurer or related in any manner to the insured;

(d) neither the organization, nor its licensed health care professionals who conduct the reviews, may receive compensation of any type that is dependent on the outcome of the review;

(e) the organization will be approved or certified by the commissioner before conducting such reviews;

(f) the organization provides a description of the fees to be charged by it for independent reviews of a long-term care insurance benefit trigger decision;

(g) the organization's fees shall be reasonable and customary for the type of long-term care insurance benefit trigger decision under review;

(h) the organization provides the name of the medical director or health care professional responsible for the supervision and oversight of the independent review procedure; and

(i) the organization will have on staff or contract with a licensed health care practitioner, as defined by Section 7702B(c)(4) of the Internal Revenue Code, who is qualified to certify that an individual is chronically ill for purposes of a qualified long-term care insurance contract.

(2) Each certified independent review organization shall:

(a) maintain written documentation, in an easily accessible and retrievable format for the year in which it received information plus two calendar years, establishing the date it received a request for independent review, the date each review was conducted, the resolution, the date such resolution was communicated to the insurer and the insured, and the name and professional status of the reviewer who conducted the review;

(b) be able to document measures taken to appropriately safeguard the confidentiality of its records and prevent unauthorized use and disclosures in accordance with applicable federal and state law;

(c) report annually to the commissioner, by June 1 (or other annual date set by the commissioner), in the aggregate and for each long-term care insurer all of the following:

(i) the total number of requests received for independent review of long-term care benefit trigger decisions;

(ii) the total number of reviews conducted and the resolution of such reviews (i.e., the number of reviews which upheld or overturned the long-term care insurer's determination that the benefit trigger was not met);

(iii) the number of reviews withdrawn prior to review; and

(iv) the percentage of reviews conducted within the prescribed timeframe set forth in ARM 6.6.3130;

(d) report immediately to the commissioner any change in its status which would cause it to cease meeting any of the qualifications required of an independent review organization performing independent reviews of long-term care benefit trigger decisions.

(3) The insurance department shall utilize the criteria set forth in ARM 6.6.3120(1)(h), in certifying or approving entities to review long-term care insurance benefit trigger decisions.

(4) The commissioner shall maintain and periodically update a list of approved independent review organizations.

 

History: 33-1-313, 33-22-1121, MCA; IMP, 33-18-201, 33-22-1102, 33-22-1121, 33-22-1124, 33-22-1125, MCA; NEW, 2019 MAR p. 126, Eff. 7/1/19.