The Medical Director’s review and recommendation is an informal alternative dispute resolution process without administrative or judicial authority and is not binding on the parties. The provisions of this rule apply to medical services provided on or after July 1, 2011.
The Medical Director is the specific individual designated by the department to review the medical records submitted for denied authorizations of treatment that have been denied for treatment of an injured worker. The Medical Director may seek consultation from other providers with specialties as would typically manage the type of medical condition being reviewed. If a consultation is sought and received, that provider’s recommendation is also subject to the provisions that govern the Medical Director. A person serving as a medical director must be a physician licensed by the State of Montana under Title 37, Chapter 3, MCA.
The Medical Director may not be called to testify in any proceeding concerning the issues discussed in the Independent Medical Review process. Any recommendations and any information contained in the recommendation that is solely from the Medical Director or Specialists consulted are not admissible as evidence in any action subsequently brought in any court of Law. The Medical Director's recommendation, including information contained in the recommendation, may be considered in mediation conducted under 39‑71‑2401, MCA.
A denied prior authorization obtained in cases where treatment(s) or procedure(s) are requested that:
(a) are not specifically addressed or recommended by the Montana Guidelines for a body part that is covered by the guideline;
(b) are after maximum medical improvement;
(c) are beyond the duration and frequency limits set out in the guidelines; or
(d) the guidelines require prior authorization before proceeding with the treatment.
The interested party or insurer must submit their request for review to the department and notify the other party of the request for the review. Complete the Independent Medical Review Report Form (IMR) and the insurer must submit a copy of the request for prior authorization, the denial, and any medical records to the department and the party requesting the review. The interested party and the insurer may also submit additional information to the department that is relevant to the Independent Medical Review. Any new information submitted to the department must also be submitted to the other party.
The Medical Director may, within 5 days of receipt of the Independent Medical Review, request additional time for review or may request additional medical records and then issue a written recommendation to the interested party and the insurer by mail, facsimile, or e-mail not to exceed 14 days from date of receipt of the request. If the medical director does not issue a recommendation within 14 days, the request for review is deemed denied and the parties may proceed to mediation.
Keep in mind this is an informal alternative to the dispute process without administrative or judicial authority and is not binding on both parties.
The insurer shall, within five days of receipt of the recommendation, notify the interested party, if the previously denied treatment(s) or procedure(s) is authorized based on the Medical Director's recommendation. If the insurer does not authorize treatment after issuance of the medical director's recommendation, the interested party may file for mediation with the department pursuant to 39-71-2401, MCA.
Maralyn Lytle, Claims Analyst Specialist
Employment Relations Division
Department of Labor & Industry
Independent Medical Review
PO Box 8011
Helena, MT 59604
Phone: (406) 444-6604