Published Utilization and Treatment Guideline Rule Change
The Montana Guidelines establish evidence-based utilization and treatment guidelines for primary and secondary medical services for workers' compensation injuries and occupational diseases, as authorized by § 39-71-704, MCA, and incorporated by reference in ARM 24.29.1591. The Guidelines include General Guideline Principles at the beginning of each chapter, which are designed to adequately and consistently address the functional improvement goals of an injured worker.
The Guidelines are applicable to all medical services provided on or after July 1, 2011. (The Guidelines establish a presumption of compensability for injuries and occupational diseases occurring on or after July 1, 2007. For those occurring on or before June 30, 2007, treatment in accordance with the guidelines constitutes reasonable primary or secondary medical treatment.)
Prior authorization is not required for treatment within the Guidelines except where indicated or for “not recommended”. Prior authorization may be obtained in specific cases for treatments outside the guidelines as provided by ARM 24.29.1593. Disputes regarding treatment and prior authorization may be brought to the Department under the Independent Medical Review process in ARM 24.29.1595. Managed Care Organizations and Preferred Provider Organizations are required to follow the Guidelines, but the Guidelines do not alter their payment agreements.
The purpose of the Guidelines is to assist injured workers in receiving prompt and appropriate care, assist injured workers in stay-at-work/return-to-work options, assist clinicians in making decisions for specific conditions, and help insurers make reimbursement determinations. Although the primary purpose of the guidelines is advisory and educational, the guidelines are enforceable for payment purposes. The department recognizes that acceptable medical practice may include deviations from these guidelines, as individual cases dictate. Therefore, these guidelines are not relevant as evidence of a provider's legal standard of professional care.