Montana Health Insurance Appeals and Grievances

What is an internal appeal?

In Montana, an internal appeal is usually called a grievance—a request that the health insurance issuer reconsider an adverse determination under MCA Title 33, chapter 32, part 3.

This is different from external review, where a CSI-approved independent review organization (IRO) decides the case after internal grievance is complete (with exceptions).

General walkthrough: Appeals roadmap.

Montana grievance timelines

Filing a grievance

• File within 180 days after the adverse determination notice (§ 33-32-308(1))
• Issuer must give you a coordinator contact and allow access to relevant records (§ 33-32-308(2), (6))
• Clinical denials reviewed by appropriate licensed professionals who did not make the initial denial (§ 33-32-308(4))

Decision deadlines

• Prospective review grievances: written decision within 30 days of receiving the grievance (§ 33-32-308(9))
• Retrospective review grievances: within 60 days (§ 33-32-308(9))
• Expedited grievances: no more than 72 hours when urgent harm is at risk (§ 33-32-309(6))

If the issuer is late

If the issuer fails to meet grievance requirements or waives review, you are treated as having exhausted internal grievance and may file for external review (§ 33-32-307(2), § 33-32-405(2)).

How to file

1. Read the adverse determination for grievance instructions and deadlines.
2. Submit a written grievance to the issuer using its required forms or process.
3. Request expedited review if delay would seriously jeopardize life, health, or maximum function.
4. Keep copies of everything submitted and the date sent.

Carrier links: Montana prior auth & internal appeals links.

Evidence that helps

• Treating clinician letter on medical necessity
• All records and information the issuer relied on—or should have considered (§ 33-32-308(5))
• Peer-reviewed literature for experimental/investigational disputes

See Building a strong appeal packet.

Medicaid appeals

Montana Medicaid managed care requires an MCO appeal before a fair hearing in most cases:

• MCO appeal: typically 60 calendar days from the adverse benefit determination (federal Medicaid standard)
• Fair hearing: written request to DPHHS within 90 days of the mailed adverse action notice (ARM 37.5.307(4)) — Office of Fair Hearings, P.O. Box 202953, Helena, MT 59620-2953

More: Medicaid managed care appeals.

After internal appeal

If the issuer issues a final adverse determination, request external review with your health insurance issuer within 120 days (§ 33-32-410(1)). You must generally exhaust internal grievance first (§ 33-32-405).

Next: Montana external review.