Montana Prior Authorization Law

What is prior authorization?

Prior authorization is part of Montana's utilization review rules. The health plan must approve certain care before it will cover it. Providers often submit requests for you, but you still have rights if PA is denied.

Overview: Prior authorizations. Montana-only details below.

Confirm plan type: Montana: Start Here.

Montana PA rules

Montana's utilization review act is in MCA Title 33, chapter 32, part 2.

Standard (prospective) review

• Notify the covered person within 7 business days after the issuer receives the request or all information needed to decide (§ 33-32-211(2))
• One extension of up to 7 additional business daysif circumstances are outside the issuer's control and the issuer notifies you in advance (§ 33-32-211(2)(c))
• Adverse determinations must include clinical rationale and grievance/appeal instructions (§ 33-32-211)

Urgent / expedited review

• Decision as soon as possible, but no later than 48 hours after receipt of an urgent care request (§ 33-32-212)
• Concurrent urgent extensions: often within 24 hours when requested at least 24 hours before authorized treatment expires (§ 33-32-212(5))

Prescription PA limits (§ 33-32-221)

Montana restricts PA on certain drugs, including when:

• A generic drug was prescribed continuously for 6 months without interruption (with exceptions)
• Prior therapeutic-duplication PA was already approved for the same dosage
• Dosage adjustments stay within FDA or accepted clinical dosing
• The drug is a long-acting injectable antipsychotic

Adverse prescription PA determinations must be made by a physician with specialty expertise in the treated condition (§ 33-32-221(2)).

Federal CMS PA timelines (7 calendar days standard / 72 hours urgent) also apply to many Marketplace, Medicare Advantage, and Medicaid managed care plans.

Where to look up PA rules

Carriers must maintain written utilization review procedures and clinical criteria (§ 33-32-207, § 33-32-211). Use your denial letter first, then your plan's provider portal.

Carrier links: Montana prior auth & internal appeals links.

Medicaid

Montana Medicaid managed care (including plans administered by BCBSMT) uses MCO prior authorization under federal Medicaid rules. Denials follow MCO grievance and DPHHS fair hearing paths—see Montana internal appeals.

If PA is denied

1. Read the denial for clinical rationale, criteria, and grievance instructions.
2. Ask your clinician for records and a letter of medical necessity.
3. File a grievance with the issuer within 180 days of the adverse determination.
4. If the grievance fails, request external review within 120 days of the final adverse determination.

Next: Montana internal appeals.

Urgent care

For urgent requests, the issuer must act within 48 hours (§ 33-32-212). If a concurrent denial occurs, service must continue without enrollee liability until notice is provided (§ 33-32-212). You may also request an expedited grievance (up to 72 hours, § 33-32-309) and simultaneous expedited external review when appropriate (§ 33-32-411).