A Consumer Guide to Handling Disputes with Your Private or Employer Health Plan
| |
Montana General Information and Internal Plan Review: Montana’s statute permits any party whose appeal of an adverse determination is denied by the health carrier or managed care entity to seek independent review of that determination by a peer. Montana requires the individual to go through the health plan’s internal review process before accessing the independent review process. Montana has few requirements for internal review processes, but health plans are required to notify you and your provider of an adverse determination within 10 calendar days from the date a decision is made regarding routine medical care, or within 48 hours (excluding Sundays and holidays) if the condition qualifies for expedited review.
If you receive an adverse determination, the health plan will send you instructions for the internal appeal or independent review.
The Independent Review Process: Whom to contact: | Your health plan | Who can appeal: | You or your authorized representative | What you can appeal: | "Adverse determinations," which are decisions by your health plan that health care services are not appropriate and medically necessary. | When you can appeal: | If your health plan has an internal appeal process, you may request an independent review of the health plan’s adverse determination within 60 days after the date the internal review decision is made. If the internal appeals process is not completed within 60 days of receipt of the request for appeal, the process is interrupted and the case is forwarded for independent review. If your health plan does not have an internal appeal process, you have 180 days following the date of its adverse decision to request an independent review. If delay threatens your life or seriously threatens your health, the internal appeal process may be bypassed. | What to send: | Your health plan will provide an explanation of your rights to appeal and instructions on how to initiate an appeal or independent review. | What you must pay: | No charge | What will happen: | You and your health plan may agree on a peer to conduct an independent review. If you are both unable to agree, your case will be forwarded to the independent review organization designated by the Department of Public Health and Human Services. | When you will get a decision: | 30 days after the review organization receives the case file (unless the review organization requests an extension from the Department). | In urgent situations: | An expedited review will be decided within 72 hours from the date the request is received. |
How to Get More Information: Montana Department of Public Health and Human Services, Quality Assurance Division,
406-444-2676 Information updated as of 9-2-2004 |
| |
