Please identify all health plans, health insurance issuers, and long-term care issuers for which the applicant currently provides
external reviews. May be attached separately:
EXTERNAL REVIEW HOTLINE
Does the applicant maintain a toll-free telephone service to receive information related to external reviews on a 24-hour-a-day, 7
day-a week basis? ☐ Yes ☐ No
If yes, is the service capable of accepting, recording, or providing appropriate instruction to incoming telephone callers during other-
than-normal business hours? ☐ Yes ☐ No
If yes, provide telephone number:
POLICIES AND PROCEDURES
Montana Code Annotated § 33-32-417 requires an independent review organization conducting health external reviews to establish
and maintain written policies and procedures that govern all aspects of both the standard external review process and the expedited
external review process.
ARM 6.6.3120(1)(h) and 6.6.3131 establish the approval standards and requirements for long-term care independent review
organizations. Companies should have policies and procedures sufficient to demonstrate compliance with the rules.
Please attach copies of policies and procedures governing all aspects of both the standard external review process and the expedited
external review process.
Please attach a document summarizing, for each policy or procedure, the aspect or aspects of external review processes that the
policy or procedure governs.
APPLICANT ATTESTATION AND CERTIFICATION
Health applicant has received accreditation as an independent review organization by accrediting body to conduct
independent external reviews. Applicant certifies that it will notify the Office of the Montana State Auditor, Commissioner of
Securities and Insurance (CSI) if accreditation is lost with the accrediting body. Applicant acknowledges that the CSI may terminate
this license if the applicant loses accreditation or no longer satisfies the minimum requirements for licensure.
Applicant acknowledges that payment of any fees associated with any external reviews conducted pursuant to Montana Code
Annotated Title 33, Chapter 32 or ARM 6.6.3130 are the sole responsibility of the health or long-term care insurance issuer whose
decision is being reviewed.
Applicant understands that it has no recourse against the CSI or the State of Montana to the extent that any health insurance or
long-term care insurance issuer fails to pay any medical reviewer fees. Applicant authorizes the CSI to verify Information with any
federal, state, or local government agency, insurance company, or accrediting organization.
Applicant acknowledges and represents that it understands and will comply with Montana’s insurance laws, including applicable
administrative rules. Health applicant further agrees to maintain and provide to the CSI the information set out in MCA § 33-32-421.
Long-term care applicant further agrees to maintain and provide to the CSI the information set out in ARM 6.6.3131 and
6.6.3120(1)(h).
I hereby certify that, under penalty of perjury, I am the person named below and know the contents of this application, and that all
the information submitted in this application and the attachments are true and complete. I attest that I have the authority and
capacity to execute this certification on behalf of Applicant. I am aware that submitting false information or omitting pertinent or
material information in connection with this application is grounds for license denial or revocation and may subject me to civil or
criminal penalties.
Name of Applicant:
Electronic Signature of Officer or Representative of Applicant:
Printed Name: Title:
Date:
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