State guide
Montana
Pick the kind of plan you have to see who to call first. Montana can only help with plans it regulates.
Which plan do you have? Who to call first, by coverage
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Your employer pays claims itself
Montana usually cannot help with these plans. Call the Employee Benefits Security Administration.
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Insurance you buy, or an employer plan bought from an insurer
Call Montana Commissioner of Securities and Insurance (CSI), Office of the Montana State Auditor. See the at-a-glance box.
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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 Montana.
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Medicare
Montana State Health Insurance Assistance Program (SHIP) gives free counseling. Or call 1-800-MEDICARE.
The short version for Montana
In Montana you send the external review request to your own insurance company, which must check eligibility within five business days and pass the case to an independent review organization; the insurer pays for it. If the insurer says you are not eligible, you can appeal that to the Commissioner of Securities and Insurance, whose consumer advocates also help with appeals. Laws that took effect in 2025 and 2026 limit prior authorization for many common drugs and make approvals last longer.
At a glance: independent review for plans Montana regulates
- Main regulator
- Montana Commissioner of Securities and Insurance (CSI), Office of the Montana State Auditor · 800.332.6148 or 406.444.2040
- Independent review
- A state process (External review by an independent review organization (IRO))
- Deadline to request it
- 120 days after you receive the notice of adverse determination or final adverse determination
- Cost
- none stated; state law makes the insurer pay the costs of the independent review organization
- Decision time
- 45 days after the review organization receives the request; fast track: 72 hours (not available for care you have already received)
Who regulates health plans
The Commissioner's office lists who to call for coverage it does not handle: for a self-funded employer health plan, the United States Department of Labor (866.444.3272) or your employer; Medicare Advantage or Part D, 800.633.4227; Medicaid, 800.362.8312; State of Montana employee plan, 406.444.7462. If you are not sure whether the office can help, call 800.332.6148.
- Montana Commissioner of Securities and Insurance (CSI), Office of the Montana State Auditor
Health insurance companies and policies subject to Montana insurance law (individual plans and fully insured employer plans). It cannot act on entities it has no regulatory authority over, such as self-funded employer plans.
Phone: 800.332.6148 or 406.444.2040. File a complaint online
Independent (external) review
- Process
- A state process. Run by Your health insurance company receives the request and assigns a review organization from the list approved by the Commissioner of Securities and Insurance.
- Where you file
- insurer
- How
- Send a written request for external review to your health insurance company, following the instructions in your final denial letter. The Commissioner's consumer advocates (800-332-6148) can help, and if the insurer says your request is not eligible you can appeal that to the Commissioner.
- Which denials qualify
- Denials because the service did not meet the insurer's requirements for medical necessity, appropriateness, health care setting, level of care or effectiveness, or was judged experimental or investigational, and rescissions of coverage.
- Appeal to the plan first?
- Yes, unless the insurer did not give a written decision on your grievance within the required time, the insurer agrees to waive the requirement, or you qualify for an expedited review because waiting would seriously jeopardize your life or health (you can ask for it at the same time as an expedited internal grievance).
Free help in Montana
- Commissioner of Securities and Insurance, Consumer Advocates
Help people with state-regulated coverage understand their policy, assist with appeals of denied health insurance claims, and require the insurer to explain and correct actions that break Montana law or the policy.
Phone: 800.332.6148 or 406.444.2040
- Montana Legal Services Association (MontanaLawHelp)
Statewide legal aid that publishes a guide and a hearing request form for appealing Montana Medicaid decisions.
Medicare and Medicaid in Montana
- Medicare counseling
- Montana State Health Insurance Assistance Program (SHIP) · 1-800-551-3191 . Free help with Medicare appeals.
- Medicaid agency
- Montana Department of Public Health and Human Services (Montana Medicaid); hearings are held by its Office of Administrative Hearings
- Fair hearing deadline
- In most Medicaid cases, 90 days from the date the notice was mailed (some cases have shorter deadlines; follow the deadline on your notice). Your notice states the deadline that applies to you.
- Good to know
- Request the hearing in writing as your notice explains. If coverage is being ended or reduced and you want benefits to continue, appeal before the change is scheduled to happen; you may have to repay if you lose. Questions about a hearing request: Office of Administrative Hearings, (406) 444-2470, hhsofh@mt.gov, PO Box 202922, Helena MT 59620, fax (406) 444-6565.
State laws that can help
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External review. You have 120 days to ask your insurer for external review, the insurer must check eligibility within 5 business days, the review organization must decide within 45 days (72 hours if expedited), and the insurer pays for the review.
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Prior authorization. Insurers cannot require prior authorization for many drugs (most generic oral and inhaled drugs, asthma and lung disease inhalers, insulin, long-acting injectable antipsychotics); a drug denial must be made by a physician who specializes in the condition and must list covered alternatives.
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Prior authorization. An approval (certification) is valid for at least 6 months, and for 12 months for treatment of a chronic condition, unless safety guidance calls for a shorter period.
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Step therapy. You cannot be made to repeat a step therapy protocol if you already tried the required drug (or one in the same class) under your current or a previous plan and stopped it because it did not work or caused harm.
Sources and what we could not confirm
- Insurance Complaints & Fraud (Montana Commissioner of Securities and Insurance)
- Insurance online complaint form (Montana Commissioner of Securities and Insurance)
- Approved Independent Review Organizations (Montana Commissioner of Securities and Insurance)
- Montana Code Annotated 33-32-410 Standard external review
- Montana Code Annotated Title 33, Chapter 32, Part 4 (External Review) index
- State Health Insurance Assistance Program (Montana Department of Public Health and Human Services)
- Office of Administrative Hearings (Montana Department of Public Health and Human Services)
- How Do I Appeal a Medicaid Decision in Montana? (Montana Legal Services Association)
- CMS: State External Appeals Review Processes
Not confirmed (8)
- The official independent review page. the Commissioner's site refers to a 'guide to internal appeals and external review' but its address was not captured; the complaints page that links to it is given
- The independent review request form. no consumer request form found; requests go to the insurer
- Which denials qualify for independent review. taken from the statute's definition of adverse determination, not from a consumer page
- The Medicaid fair hearing deadline. the 90-day figure comes from Montana Legal Services Association (updated November 2026); the state hearings page only says to follow your notice
- The Medicare counseling program's phone number. the state page prints 1-800-551-3191 while the federal SHIP directory lists 406-444-4077; the state number is used
- Free consumer help programs. no phone number confirmed for Montana Legal Services Association
- Free consumer help programs. the federal directory lists Montana as having a Consumer Assistance Program but no separate program page was found; the Commissioner's consumer advocates are listed
- State laws that help. bill number and codified section for the step therapy provision were not confirmed, only the session law chapter