Montana External Review (CSI / IRO)

What is external review?

External review assigns a CSI-approved independent review organization (IRO)to decide whether the issuer's adverse determination was correct. Montana's program is in MCA Title 33, chapter 32, part 4.

You file the external review request with your health insurance issuer, not directly with the IRO. The issuer assigns an IRO from the commissioner's approved list. The IRO is not bound by the issuer's earlier utilization review or grievance decisions (§ 33-32-410(7)).

General overview: Appeals roadmap. Complete Montana internal appeals first unless an exception applies.

Who can use Montana review?

External review generally applies when:

• You have a Montana-regulated fully insured health plan
• The dispute involves medical necessity, appropriateness, experimental/investigational treatment, or similar clinical judgments
• You exhausted internal grievance (or qualify for an exception under § 33-32-405 or § 33-32-307)

Usually does not apply to:

• Self-funded ERISA employer plans
• Montana Medicaid (DPHHS fair hearing)
• Medicare

Deadlines & exhaustion

120-day filing window

File a written external review request with your health insurance issuer within 120 days after the adverse determination or final adverse determination (§ 33-32-410(1)). This is longer than the federal Marketplace four-month rule in some other states—still follow any deadline in your denial letter if it is shorter.

Exhaust internal grievance first

Generally complete the issuer's grievance process under part 3 before external review (§ 33-32-405(1)). Exceptions include:

• No timely grievance decision after you filed (§ 33-32-405(2), § 33-32-307(2))
• Issuer agrees to waive exhaustion (§ 33-32-405(5))
• Expedited external review filed with simultaneous expedited grievance when urgent (§ 33-32-405(4), § 33-32-411)
• Retrospective denials: must complete full internal grievance—no shortcut (§ 33-32-405(3))

How to file

1. Complete internal grievance and obtain a final adverse determination when required.
2. Submit a written external review request to your health insurance issuer within 120 days.
3. The issuer has 5 business days for a preliminary eligibility review and must notify you within 1 business day after that (§ 33-32-410(2)–(3)).
4. If eligible, the issuer assigns an IRO from CSI's approved list within 1 business day (§ 33-32-410(6)).
5. Contact CSI for help: 800-332-6148 or 406-444-2040 (csimt.gov). You may appeal to the commissioner if the issuer says you are ineligible (§ 33-32-410(3)–(5)).

Links hub: Montana external appeals links.

How long it takes

• Standard review: IRO decision within 45 days after receiving the external review request (§ 33-32-410(20))
• Expedited review: no more than 72 hours when urgent (§ 33-32-411(9)); not available for retrospective denials (§ 33-32-411(11))

Is the decision binding?

For eligible clinical disputes, the IRO decision is binding on the health insurance issuer. If the IRO reverses the denial, the issuer must immediately approve coverage (§ 33-32-411(10)).

Medicaid & Medicare

Montana Medicaid: MCO appeal, then DPHHS fair hearing—not commercial external review under chapter 32, part 4.

Medicare & Medicare Advantage: Federal Medicare appeals through CMS.

More: Medicaid managed care · Medicare appeals.