Montana routes external review through your insurer — and the state's list

A drug denial needs the matching specialty

Montana defines a clinical peer as a provider with a nonrestricted licence who is trained or works in the same or a similar specialty to the one that typically manages the condition, procedure or treatment under review. For prescription drugs it goes further: any adverse determination made during prior authorization must be made by a physician whose specialty focuses on the diagnosis and treatment of the condition the drug was prescribed to treat.

The notice must also state the specific rule, guideline, protocol or criterion relied on, or explain the scientific or clinical judgment behind the determination.

How Montana's external review works

Montana's external review is set in statute (Title 33, Chapter 32, MCA) and overseen by the Commissioner of Securities and Insurance, part of the Office of the State Auditor. The mechanics are distinctive: you file the request with the insurer, not the state — but the insurer doesn't get to hand-pick the reviewer. Within one business day it must randomly assign an independent review organization from the Commissioner's approved list, which keeps the choice neutral.

• The request is filed with the health insurer, which must forward it for review.
• The insurer randomly assigns the IRO from the Commissioner's approved list — no cherry-picking the reviewer.
• The IRO's decision binds the plan.
• The Commissioner's consumer advocates help with denied-claim appeals at no cost (800-332-6148).

The 120-day deadline

You have 120 days after you receive the notice of the plan's adverse (or final adverse) determination to file a request for external review with your insurer. Miss it and the case is time-barred, so start the request promptly once the denial arrives.

How to file

1. 1

   Exhaust the internal appeal

   Complete the plan's internal appeal first (urgent cases can move in parallel).

2. 2

   File the request with your insurer

   Montana's statute routes the external-review request through the health insurer, not the state agency.

3. 3

   The insurer assigns an IRO at random

   Within one business day, the insurer randomly assigns an independent review organization from the Commissioner's approved list.

4. 4

   Get help if you need it

   The Commissioner's Consumer Advocates (800-332-6148) assist with appeals for free.

How fast — and who pays

• Standard: the IRO decides within 45 days of receiving the request; you can submit additional information within 10 business days of the assignment notice.
• Expedited (urgent): within 72 hours.
• There is no filing fee for the consumer.
• The decision is binding on the plan.

The drugs Montana took out of prior authorization

Montana's prior-authorization statute (Mont. Code Ann. § 33-32-221, enacted in 2023 and amended in 2025) does not merely regulate how prior authorization is run — it removes named categories from it. Before appealing a drug denial on clinical grounds, it is worth checking whether the plan was entitled to require authorization at all:

• A generic drug the patient has taken continuously for six months.
• A dosage adjustment inside the FDA-approved range.
• Long-acting injectable antipsychotics.
• Insulin that is on the plan's formulary.
• FDA-approved substance-use-disorder treatments prescribed at the labelled dosage.
• Drugs on the FDA shortage list.
• Separately, under § 33-22-127, oral therapy for opioid use disorder is exempt from both prior authorization and step therapy.

Who has to sign a drug denial — and how long an approval holds

Two more provisions shape what a defensible denial looks like in Montana. An adverse determination on a drug prior authorization must be made by a physician in the same specialty, and the denial has to come with a list of the covered therapeutic alternatives — a denial that names no alternative is incomplete on its face. And under § 33-32-107, a utilization-review approval stays valid for at least three months, so a service denied inside that window after it was approved is a question about the approval, not about medical necessity.