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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
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