# Mont. Code Ann. § 33-32-210: 33-32-210 Qualifications of individuals making or reviewing adverse determinations

> Montana · Statutes · In force

URL: https://www.frixlaw.com/law-library/statutes/STATE_MT_T33_C32_P2_S33-32-210

## Section

- **Citation:** Mont. Code Ann. § 33-32-210
- **Heading:** 33-32-210 Qualifications of individuals making or reviewing adverse determinations
- **Jurisdiction:** Montana
- **Kind:** Statutes
- **Status:** In force
- **Text as of:** August 14, 2026
- **Source:** Compiled text
- **Location:** MT Code / Title 33 / Chapter 32 / Part 2 / Section 33-32-210

## Text

33-32-210 . (Effective January 1, 2026) Qualifications of individuals making or reviewing adverse determinations. (1) A health insurance issuer or its utilization review organization shall ensure that all adverse determinations pursuant to 33-32-211 or 33-32-212 are made by:

(a) a physician when the request is by or on behalf of a physician; or

(b) a health care professional licensed in the same profession as the health care professional making the request, or, in any case, by a physician.

(2) A physician or other health care professional making an adverse determination pursuant to subsection (1) must:

(a) possess a current and valid nonrestricted license; and

(b) have experience treating and managing patients with the medical condition or disease for which the health care service is being requested, or shall refer the review to a physician with the requisite specialized knowledge and experience.

(3) A health insurance issuer or its utilization review organization shall ensure that only a physician reviews a grievance as provided under 33-32-308 or 33-32-309 . A physician making an adverse determination or reviewing a grievance must:

(a) possess a current and valid nonrestricted license to practice medicine; and

(b) be of a specialty that focuses on the diagnosis and treatment of the condition that is being treated.

(4) A health insurance issuer or its utilization review organization must make all adverse determinations under the clinical direction of one of the utilization review organization's medical directors who is responsible for the oversight of the utilization review activities for covered persons in the state. A medical director used for this purpose must be a licensed physician.

(5) For the purposes of this section, "adverse determination" has the same meaning as provided in 33-32-102 (1)(a) or (1)(c).

## Nearby sections

- [Mont. Code Ann. § 33-32-202 33-32-202 Commissioner not to approve or disapprove plans](https://www.frixlaw.com/law-library/statutes/STATE_MT_T33_C32_P2_S33-32-202.md)
- [Mont. Code Ann. § 33-32-205 33-32-205 Corporate oversight of utilization review program](https://www.frixlaw.com/law-library/statutes/STATE_MT_T33_C32_P2_S33-32-205.md)
- [Mont. Code Ann. § 33-32-206 33-32-206 Responsibility for contracted services](https://www.frixlaw.com/law-library/statutes/STATE_MT_T33_C32_P2_S33-32-206.md)
- [Mont. Code Ann. § 33-32-207 33-32-207 Health insurance issuer duties for utilization review](https://www.frixlaw.com/law-library/statutes/STATE_MT_T33_C32_P2_S33-32-207.md)
- [Mont. Code Ann. § 33-32-208 33-32-208 Operational requirements](https://www.frixlaw.com/law-library/statutes/STATE_MT_T33_C32_P2_S33-32-208.md)
- [Mont. Code Ann. § 33-32-209 33-32-209 Exemption for continuity of care on change in health plans](https://www.frixlaw.com/law-library/statutes/STATE_MT_T33_C32_P2_S33-32-209.md)
- [Mont. Code Ann. § 33-32-210 33-32-210 Qualifications of individuals making or reviewing adverse determinations](https://www.frixlaw.com/law-library/statutes/STATE_MT_T33_C32_P2_S33-32-210.md)
- [Mont. Code Ann. § 33-32-211 33-32-211 Procedures for standard utilization review and benefit determinations -- notices](https://www.frixlaw.com/law-library/statutes/STATE_MT_T33_C32_P2_S33-32-211.md)
- [Mont. Code Ann. § 33-32-212 33-32-212 Procedures for expedited utilization review and benefit determinations](https://www.frixlaw.com/law-library/statutes/STATE_MT_T33_C32_P2_S33-32-212.md)
- [Mont. Code Ann. § 33-32-215 33-32-215 Emergency services](https://www.frixlaw.com/law-library/statutes/STATE_MT_T33_C32_P2_S33-32-215.md)
- [Mont. Code Ann. § 33-32-216 33-32-216 Confidentiality](https://www.frixlaw.com/law-library/statutes/STATE_MT_T33_C32_P2_S33-32-216.md)
- [Mont. Code Ann. § 33-32-217 33-32-217 Disclosure](https://www.frixlaw.com/law-library/statutes/STATE_MT_T33_C32_P2_S33-32-217.md)
- [Mont. Code Ann. § 33-32-221 33-32-221 Prior authorization requirements](https://www.frixlaw.com/law-library/statutes/STATE_MT_T33_C32_P2_S33-32-221.md)
- [Mont. Code Ann. § 33-32-222 33-32-222 Prohibition on prior authorization requirements for prescriptions written at discharge from inpatient care](https://www.frixlaw.com/law-library/statutes/STATE_MT_T33_C32_P2_S33-32-222.md)

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Source: Frix Law Library, https://www.frixlaw.com/law-library/statutes/STATE_MT_T33_C32_P2_S33-32-210. Check the current official text before relying on it. Not legal advice.