New to helping someone in Montana?
You do not need a law degree to help someone fight a health insurance denial. Start by gathering three basic documents:
- Insurance card — shows which company administers the plan. Use the name and phone number on the card when you call or file paperwork.
- Denial letter or explanation of benefits (EOB) — the notice that says a service was denied, not paid, or needs approval first. Look for appeal instructions and a deadline.
- Summary of Benefits and Coverage (SBC) — helps you tell whether the fight is about medical necessity or whether the benefit exists at all.
Your first tasks: identify what type of plan this is (Marketplace, job-based, Medicaid, Medicare) and write down the appeal deadline from the letter.
Montana law uses adverse determinations and grievances. You usually file a grievance with the insurer first, then may request external review through an independent review organization (IRO) assigned under rules enforced by the Commissioner of Securities and Insurance (CSI).
For steps that work in every state, read these general guides first, then return here for Montana rules:
What is different in Montana?
- HealthCare.gov Marketplace: Montana uses the federal Marketplace at HealthCare.gov. Major individual-market carriers include Blue Cross Blue Shield of Montana and Montana Health CO-OP (Mountain Health Co-op). Check current year availability in your county.
- Prior authorization (MCA Title 33, ch. 32, pt. 2): 7 business days prospective / 48 hours urgent; certain prescription PA limits under § 33-32-221.
- Internal grievances: File within 180 days of the adverse determination; insurer decision often within 30 days (prospective) or 60 days (retrospective).
- External review: Request with your health insurance issuer within 120 days of the final adverse determination; IRO decision within 45 days (72-hour expedited when urgent).
- Medicaid (Montana Medicaid / HMK): MCO appeal first, then DPHHS fair hearing—separate from commercial external review.
Who is in charge of your plan?
- CSI (Commissioner of Securities and Insurance): IRO oversight, grievance compliance, consumer help — csimt.gov. Insurance Consumer Hotline: 800-332-6148 or 406-444-2040.
- U.S. Department of Labor: Many self-funded employer plans.
- DPHHS — Office of Fair Hearings: Medicaid fair hearings — P.O. Box 202953, Helena, MT 59620-2953.
- CMS: Medicare and Medicare Advantage.
After appeals are exhausted, see Regulator complaints.