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24.29.1601    DEFINITIONS

As used in this subchapter, the following definitions apply:

(1) "Claim" means an injury or occupational disease where:

(a) liability has been accepted by the insurer; or

(b) payment has been made by the insurer pursuant to:

(i) 39-71-608, MCA;

(ii) 39-71-615, MCA; or

(iii) any other reservation of rights.

(2) "Department" means the Department of Labor and Industry, Employment Relations Division.

(3) "Evidence-based" means use of the best evidence available in making decisions about the care of the individual patient, gained from the scientific method of medical decision-making and includes use of techniques from science, engineering, and statistics, such as randomized controlled trials (RCTs), meta-analysis of medical literature, integration of individual clinical expertise with the best available external clinical evidence from systematic research, and a risk-benefit analysis of treatment (including lack of treatment).

(4) " Formulary" means the list of drugs for which prior authorization is generally not needed, as adopted and automatically updated pursuant to ARM 24.29.1616.

(5) "Formulary rules" means:

(a) ARM 24.29.1601;

(b) ARM 24.29.1607;

(c) ARM 24.29.1616;

(d) ARM 24.29.1624;

(e) ARM 24.29.1631;

(f) ARM 24.29.1645; and

(g) ARM 24.29.1648.

(6) "Insurer" means compensation plan No. 1, plan No. 2, and plan No. 3.

(7) "Legacy claim" means a workers' compensation or occupational disease claim with an occurrence date before April 1, 2019.

(8) "Medical director" means a person who is an employee of, or contractor to, the department, and who is responsible for the independent medical review of requests for treatment(s) or procedure(s), when those requests are denied, and whose responsibility will also include other areas to be determined by the department. A person serving as a medical director must be a physician licensed by the state of Montana under Title 37, chapter 3, MCA.

(9) "Montana Guidelines" are the Montana utilization and treatment guidelines adopted by the department in ARM 24.29.1611.

(10) "ODG drug formulary" means the ODG Workers' Compensation Drug Formulary published by MCG Health, LLC.

(11) "PBM" mean the pharmacy benefits manager used by an insurer to help the insurer implement the formulary's use in the insurer's claims handling processes.

(12) "Primary medical services" has the same meaning as provided by 39-71-116, MCA.

(13) "Prior authorization" means the interested party receives prior authorization (either verbally or in writing) from the insurer:

(a) to perform treatment for those cases identified by ARM 24.29.1621; or

(b) to obtain medications for those cases identified in the formulary rules as requiring prior authorization.

(14) "Rebuttable presumption" means that the Montana Guidelines, as adopted in ARM 24.29.1611, are presumed to be compensable medical treatment for an injured worker. The presumption can be rebutted by a preponderance of credible medical evidenced-based material and medical reasons to justify that the medical treatment(s) or procedure(s) that require prior authorization are reasonable and necessary care for the injured worker.

(15) "Refill" means the dispensing of additional medications after the initial number of doses authorized by a written prescription have been dispensed, where the prescription expressly indicates that a certain number of refills are allowed without the need for another written prescription.

(16) "Supportive services" means those treatments, therapies, and related services that are designed to safely, effectively, and compassionately assist an injured worker transition from an existing medication regimen.

(17) "Treating physician" has the same meaning as provided by ARM 24.29.1401A.

(18) "Treatment" has the same meaning as provided by ARM 24.29.1401A.

(19) "Treatment plan" means a written outline of how the provider intends to treat a specific condition or complaint. A treatment plan includes a transition plan provided for in ARM 24.29.1631. A treatment plan must be made in accordance with the Montana Guidelines adopted in ARM 24.29.1611 and made in accordance with any insurer authorized treatments or procedures.


History: 39-71-203, 39-71-704, MCA; IMP, 39-71-704, MCA; NEW, 2018 MAR p. 2531, Eff. 1/1/19.

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