Montana program
Appeal a denial outside the plan (Montana external review)
An independent reviewer can reconsider certain health-plan denials (Montana external review).
What it is
An independent reviewer can reconsider certain health-plan denials (Montana external review).
An insurer's final no is not always the last word. On an insured Montana plan, a reviewer outside the company decides. A plan where the employer pays its own claims uses a federal route instead; one question to HR settles which.
Eligibility rules
- A qualifying state external-review request is due within 120 days after you receive the adverse determination.
- State rules cover issuers offering health plans and performing utilization review.
- Your social worker can help the Montana insurance office identify whether state external review covers this plan and denial. Normally the internal appeal comes first, but missed procedural deadlines, a waiver or a qualifying urgent case can allow an earlier external request. A private self-funded work plan generally uses federal review rights instead; government and school plans need a plan-specific check and should not automatically be called ERISA plans. The request route and deadline in the denial notice matter.
What you get
- An independent decision on a qualifying denial.
- Faster review when urgent criteria are met.
What it covers
- The reviewer can uphold or overturn a denial. Review does not promise approval.
If you decide to apply
- Ask the state insurance office to identify the review route.
- Bring the denial, internal appeal decision, plan booklet and doctor’s medical-need explanation.
1-800-332-6148 — Montana Commissioner of Securities and Insurance consumer assistance · Official page ↗
After you ask
- For a qualifying standard external review, the reviewer has 45 calendar days after receiving the request to decide.
- Eligible urgent external reviews have a 72-hour decision clock. Medical-risk conditions apply, and this route does not cover every retrospective bill dispute.
Good to know
Cancer alone does not make every request urgent. The team must explain why waiting is unsafe.
Other details
- The date you receive the notice matters; keeping the letter and envelope can help establish the deadline.
Official sources
- Montana Legislature: MCA 33-32-404 — External review requests
- Montana Legislature: MCA 33-32-410 — Standard external review
- Montana Legislature: MCA 33-32-411 — Expedited external review
- Montana Legislature: MCA 33-32-105 — Applicability
- Montana Commissioner of Securities and Insurance: Montana Health Answers
“Would outside review help if our plan denies care? What limits and deadlines apply, and could you help prepare a request if it fits?”
Why I’m asking: I want to understand options if insurance will not cover recommended care.
More background and detailed requirements
Additional program information and published rules
Who does what
The three parts, side by side. The agency decides; nobody on this page does.
You
Ask in writing within 120 days and say if it is urgent.
Your social worker
The oncology team writes why the treatment is medically necessary.
The care team
Writes the letter of medical necessity and marks it urgent when it is.
- Who decides
- An independent review organisation.
- Ask the agency
- “I want to request an external review of this denial. My child is in cancer treatment, so please treat it as expedited.”
How to apply
First step: Diary 120 days from the denial letter and write to the insurer asking for external review.
- Diary 120 days from the denial letter.
- Ask the oncology team for the letter of medical necessity the same week.
- If care cannot wait, ask for the expedited route by name.
Official application / program page ↗
Where it starts: Write to the insurer asking for external review. The state insurance office can help.
What to gather
- The denial letter and the internal appeal decision
- The letter of medical necessity
- The plan booklet
How long: 45 days for a standard decision, 72 hours when expedited.
What a yes looks like
The reviewer overturns the denial and the plan has to follow it.
What a no looks like, and the next move
The reviewer upholds the denial. Ask the state insurance office what else is open.
Watch out
- The 120 days run from the denial letter, not from when you get to it.
- A private-employer self-funded plan uses the federal route instead.
- Whether the rules reach a state-employee or teacher plan is not settled; ask the administrator.
The numbers and the rules
The arcane layer, kept on purpose. Checked September 11, 2026.
What it is worth
Independent review of a denial: 120 days to ask, 45 days for a decision, 72 hours when it is urgent.
- $120 — Days to request a standard external review
- $45 — Days for the independent reviewer to decide
- $72 — Hours for an expedited decision
Legal protection: An independent reviewer decides, not the insurer · An expedited route exists for urgent care
What it costs the family: None.
The eligibility facts, as published
- Plan type
- issuers offering a health plan and performing utilization review; applicability to self-funded, state-employee, teacher and municipal plans was NOT FOUND
- Deadline
- 120 days from the qualifying adverse determination
The trap: The 120 days run from the qualifying denial, not from when you get around to it. Put the date in a diary the day the letter arrives.
Where I read this
- MCA 33-32-404 — External review requests — Montana Legislature, read September 10, 2026
- MCA 33-32-410 — Standard external review — Montana Legislature, read September 10, 2026
- MCA 33-32-411 — Expedited external review — Montana Legislature, read September 10, 2026
- MCA 33-32-105 — Applicability — Montana Legislature, read September 10, 2026
- Montana Health Answers — Montana Commissioner of Securities and Insurance, read September 10, 2026