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Procedures for Claiming Benefits

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If you believe that you have been inappropriately denied payment of a claim as described in the Summary Plan Document:

  1. Call the appropriate third party administrator (Allegiance, Delta Dental, MedImpact, or the Standard) for an explanation. 
  2. If you believe the response from the plan administrator is incorrect, send a written Level 1 Review.
  3. If you are not satisfied with the response to the Level 1 Review, you may request a formal Level 2 Review*.

*A Level 1 Review must be conducted prior to a request for a Level 2 Review. Typically most issues can be solved through the less formal Level 1 Review process.

Level 1 Review

Medical and Dental Claims
When a claim for medical or dental benefits is processed, you will receive an Explanation of Benefits (EOB) from the company that processed the claim. This provides an explanation of any denials or reduction in benefits. You may request further explanation of the reasons by calling the number on the EOB or the customer service number on your identification card for the plan. If not satisfied with the explanation, you may send a written request for a Level 1 Review within 90 days of receipt of the EOB to your plan administrator (Allegiance for medical or Delta Dental for dental).

Prescription Drug Claims
If you believe that you have been inappropriately denied prescription drug benefits described in the Summary Plan Document, you are encouraged to call the customer service number on your prescription drug identification card for an explanation. If you are unsatisfied with the response, you may submit a written informal, or Level 1, appeal to MedImpact within 60 days of the denial or benefit reduction you are appealing.

Life Insurance and Accidental Dealth & Dismemberment (AD&D) Claims 
If you receive a notice that a life or AD&D insurance claim has been denied, you may call the Standard Insurance Company for an explanation. If you are not satisfied, you may send a written request for a review along with supporting documentation to The Standard Insurance Company within 60 days of receipt of the denial.

Vision Hardware Claims
If you are denied vision insurance benefits, you or your vision provider may call Cigna VSP for an explanation. If you are unsatisfied with the response, you may send a written request for a review to Cigna VSP within 60 days.

Level 2 Review

Medical, Vision Hardware, and Dental Claims
If you are not satisfied with the response to a Level 1 Review, you may initiate a formal petition for Level 2 Review by Health Care and Benefits Division (HCBD). A petition for review must be in writing, stating the reason or reasons you or your health care provider are disputing the denial, and include documentation of the informal review process. This petition must be filed with HCBD within 90 days of the date of the notice of the informal review denial.

HCBD will review the arguments presented and may forward the petition to the claims administrator who denied the claim for a formal reconsideration, if circumstances warrant. A written decision will be made by HCBD within 30 days of the date the petition is filed or within 120 days if special circumstances require an extension.

HCBD
PO Box 200130
Helena, MT 59620-0130
(800) 287-8266; (406) 444-7462; TTY (406) 444-1421
www.benefits.mt.gov
benefitsquestions@mt.gov

Prescription Drug Claims
If you are not satisfied with the response to the Level 1 Review of a prescription drug claim, you may submit a second appeal to MedImpact within 60 days of receipt of the response. The claim will be reviewed by a special review committee of representatives of MedImpact. A written response will be issued within 30 days, or within 60 days if special circumstances require an extension.

Life Insurance and Accidental Dealth & Dismemberment (AD&D) Claims 
Since  life and accidental death and dismemberment insurance plans are not self-insured by your employer, final claims decision are made by the relevant insurance company. You may request information from HCBD about the policy and contract terms by submitting a copy of the denial and other documentation to HCBD within 60 days of receipt of the decision.

Expedited Internal Appeal

An expedited internal appeal is for having services prior authorized in an emergency or life-threatening situation. Expedited internal appeals are only applicable to those emergency situations where treatment has not yet been received. This process cannot be used after the services have already been performed.

You can request an expedited internal review by fax (406) 444-0080, phone (800) 287-8266, or TTY (406) 444-1421.

The appeal will be reviewed by a licensed covered provider. A decision will be made within two business days of receiving notice of the request for the expedited review and receipt of all necessary information.

Expedited Federal External Review Process

There may be situations where the 48 hour process may jeopardize the life or health of the member or the member's ability to regain maximum function. In those rare instances, the member has the option of the Expedited Federal External Review process.

If the State plan gets one of these appeals, the review described under Expedited Internal Appeals above must be completed within 24 hours of the business day on which the appeal is received. Then within 24 hours of the preliminary review or on the next business day, the State plan must provide a written notice to the member detailing whether the claim is eligible for external review and, if not eligible, why not and what materials are needed to complete the request.

If the appeal is eligible for external review, the State plan assigns the appeal to an Independent Review Organization (IRO). The IRO then reviews the appeal request as quickly as the member's medical condition requires. Under no circumstances may the IRO take longer than 72 business hours to complete the review process from the time the IRO receives the request.


Member Responsibility
Failure to file a petition for Level 1 review within Level 1 time frames or to file a petition for a Level 2 review within Level 2 time frames shall constitute a waiver of the right to file or continue a Level 2 petition.

Appeal of Prior Authorization and Certification Actions
If you are informed that requested services will be denied as not medically necessary or not a benefit of the plan, you may initiate a Level 1 and Level 2 review as described above.