After No
Urgent help
Menu Close

State guide

Idaho

Pick the kind of plan you have to see who to call first. Idaho can only help with plans it regulates.

On this page 8

Which plan do you have? Who to call first, by coverage

  • Your employer pays claims itself

    Idaho usually cannot help with these plans. Call the Employee Benefits Security Administration.

    Call 1-866-444-3272

  • Insurance you buy, or an employer plan bought from an insurer

    Call Idaho Department of Insurance. See the at-a-glance box.

    Call 208-334-4250

  • Medicaid or children's coverage

    Call the number on your notice and ask to appeal, and to keep services going while you appeal. The hearing deadline is under Medicaid in Idaho.

    Medicaid in Idaho

  • Medicare

    Senior Health Insurance Benefits Advisors (SHIBA), Idaho Department of Insurance gives free counseling. Or call 1-800-MEDICARE.

    Call 1-800-247-4422 1-800-633-4227

The short version for Idaho

Idaho runs its own external review through the Department of Insurance, and the insurer pays for it. The department's request form warns that, except in limited circumstances, the independent reviewer's decision is binding and final and you give up having a court or arbitrator review the claim afterward, so read that section before you sign. The same department runs the consumer hotline and the Medicare counseling program.

At a glance: independent review for plans Idaho regulates

This box is for insurance you buy, or an employer plan bought from an insurer. It is not for Medicaid, Medicare or a plan your employer funds itself.

Main regulator
Idaho Department of Insurance · 208-334-4250; toll-free in Idaho 1-800-721-3272
Independent review
A state process (External review)
Deadline to request it
4 months (the department's page also says no later than 120 days) from the date of the insurer's final denial
Cost
None; the insurance company pays the cost of the external review
Decision time
42 days after the independent review organization receives the request from the Department of Insurance; fast track: 72 hours after the independent review organization receives an expedited request

Your own notice states the deadline and process for your plan, and controls if it differs. Plans your state does not regulate (for example job-based plans the employer funds itself) follow federal rules; see who regulates your plan.

Who regulates health plans

Independent (external) review

Process
A state process. Run by Idaho Department of Insurance, which assigns an independent review organization.
Where you file
regulator
How
Fill in the Health Claims External Review Request Form and send it to the Department of Insurance with a copy of your insurance card and the insurer's final denial letter. Mail to Idaho Department of Insurance, ATTN: External Review, 700 W. State St., P.O. Box 83720, Boise, ID 83720-0043, fax 208-334-4398, or email consumeraffairs@doi.idaho.gov. For an urgent case, your treating provider must complete the certification attached to the form.
Which denials qualify
Denials based on medical necessity, appropriateness, health care setting, level of care or effectiveness of the treatment, and denials that call the treatment investigational
Appeal to the plan first?
Yes. You must exhaust all levels of the insurer's internal appeals or grievances first, unless the insurer waives that requirement; the request form says you may also skip it "under certain circumstances" without listing them.
Published results
The department's external review page publishes yearly counts for 2018 to 2020. In 2020 it received 155 requests: 27 denials were overturned, 43 were upheld and 42 were not eligible for review. In 2019: 155 requests, 35 overturned, 52 upheld, 29 not eligible. Source

Official page Request form

General rules and what to send: how external review works, how to request it.

Free help in Idaho

Medicare and Medicaid in Idaho

Medicare counseling
Senior Health Insurance Benefits Advisors (SHIBA), Idaho Department of Insurance · 1-800-247-4422 . Free help with Medicare appeals.
Medicaid agency
Idaho Department of Health and Welfare (Idaho Medicaid)
Fair hearing deadline
30 days from the date on your notice for Medicaid eligibility and benefit decisions; 28 days from the date on your notice for decisions about Medicaid services (such as level of care or developmental disability services). Your notice states the deadline that applies to you.
Good to know
To keep receiving benefits during the appeal you must say so within 10 days of the date of the notice, and you may have to repay them if you lose. File by mail to Self-Reliance Programs, P.O. Box 83720, Boise, ID 83720-0026, by email to mybenefits@dhw.idaho.gov, by fax to 866-434-8278 or by phone at 877-456-1233. Hearings are held by the Office of Administrative Hearings.

Medicaid appeals page How Medicaid appeals work

State laws that can help

  • External review. Gives people with Idaho health insurance the right to an independent external review of medical necessity and investigational denials, paid for by the insurer and binding on it.

    Idaho Health Carrier External Review Act, Idaho Code Title 41, Chapter 59

  • Prior authorization. A managed care organization must answer a non-emergency prior authorization request within two business days of getting complete medical information, and once it approves a service that is then provided it generally cannot take the approval back.

    Idaho Code section 41-3930

State laws usually reach only plans your state regulates. They often do not reach job-based plans the employer funds itself.

Sources and what we could not confirm

Read from official pages on . Phone numbers and deadlines change; check the official page before you rely on one.

  1. Affordable Care Act: Working with States to Protect Consumers (State External Appeals Review Processes), Centers for Medicare & Medicaid Services
  2. Idaho Health Insurance Consumer Help, Centers for Medicare & Medicaid Services
  3. External Review, Idaho Department of Insurance
  4. External Review Questions, Idaho Department of Insurance
  5. Health Claims External Review Request Form, Idaho Department of Insurance
  6. File a Consumer Complaint, Idaho Department of Insurance
  7. Senior Health Insurance Benefits Advisors, Idaho Department of Insurance
  8. Appeals and Fair Hearings, Idaho Department of Health and Welfare
  9. Idaho Code section 41-3930, Utilization management program requirements
Not confirmed (6)
  • How to tell whether the state regulates your plan. the Department of Insurance pages loaded do not say how to tell whether a plan is state-regulated
  • Whether you must appeal to the plan first. the exceptions are mentioned on the request form but not listed there; the statute text was not loaded
  • Published results of independent review. the newest figures on the department's page are for 2020; the overturned, upheld and not-eligible counts do not add up to the total and the page does not explain the difference
  • A searchable list of past decisions. none found
  • State laws that help. the chapter link is the one printed on the department's page; the chapter text itself was not loaded
  • State laws that help. no Idaho step therapy, surprise billing or prior authorization reform law was confirmed; a 2026 bill (House Bill 611, Idaho Prior Authorization Reform Act) was seen as introduced only

Sources last checked . Found a mistake? Report it.