If we have denied your request for benefits in whole or in part, or you are otherwise dissatisfied with the decision, you, or someone you authorize, can appeal our decision. This document explains your appeal rights.
What if I need help understanding a denial?
Contact Customer Service at the number listed on the back of your Member ID card if you need assistance understanding this notice or our decision to deny you a service or coverage.
What if I don’t agree with a coverage decision?
You have a right to appeal any decision not to provide you with a service or to pay for an item or service (in whole or in part).
Who may file an appeal?
You or someone you name to act for you (your authorized representative) may file an appeal. Contact Customer Service to obtain a form for designating an authorized representative or you may visit www.mountainhealth.coop for the form.
How do I file an appeal?
You have 180 days from the day you receive this notification to appeal our decision. You or your authorized representative may send a written request that includes your name, your provider’s name, the date of service, your (or your representative’s) mailing address, an explanation of why we should reverse our decision, and a copy of any information that will support your request. You may provide us with any additional documents, records, or information that are relevant to your appeal. Submit your appeal to: Appeals Team, Mountain Health Co-Op, PO Box 5358, Helena, MT 59604, use our Fax Number: 406-513-1045, or email [email protected]. If you or your representative cannot file a written appeal, you may file an appeal online at www.mountainhealth.coop. Oral appeals requests are made by calling: (833) 412-4144.
If your appeal is in response to a decision that was based in whole or in part on a medical judgment, your appeal will be considered by persons not involved in, or subordinate to anyone involved in the initial determination. If necessary, we will consult with a health care professional who has the appropriate training and experience in the field of medicine necessary for making this medical judgment.
If your appeal is an administrative appeal (not based on medical judgment), your appeal will be considered by individuals who were not involved in the initial decision.
For all non-urgent appeals, the appeals team will acknowledge your request within 5 business days of receipt. We will notify you of our decision within 30 days for pre-service appeals and 60 days for post-service appeals.
What if my situation is urgent?
If your situation meets the definition of urgent under the law, your review will be conducted within 72 hours. Generally, an urgent situation is one in which your health may be in serious jeopardy, or, in the opinion of your physician, you may experience pain that cannot be adequately controlled while you wait for a decision on your appeal. It may concern an admission; a continued stay or other health care services related to a person who received emergency services but has not been discharged from a facility. If you believe your situation is urgent, you may visit www.mountainhealth.coop to file online. Or you may request an expedited appeal by calling (833) 412-4144.
Can I request copies of information relevant to my claim?
Yes, you may request copies (free of charge) by contacting Customer Service at the number listed on the back of your Member ID card.
What happens next?
If you appeal, we will review our decision and provide you with written determination. If we continue to deny the payment, coverage, or service requested, and you have exhausted the internal appeal process or you do not receive a timely decision, you may be able to request an external review. You have 4 months following the receipt of the adverse determination to request an external review. You have the right to have our decision reviewed by an Independent Review Organization (IRO), by health care professionals who have no association with us, if our decision involved making a judgment as to the medical necessity, appropriateness, health care setting, level of care, or level of effectiveness of the health care service or treatment you requested. You may file an External Review request with the Idaho Department of Insurance. Submit the request in writing to Idaho Department of Insurance, Attn: External Review, 700 W. State Street, 3rd Floor, Boise, ID 83720-0043.
For more information and for an External Review request form, see the Idaho Department of Insurance website at www.doi.idaho.gov or call (208) 334-4250. You also have the right to concurrently file an Urgent Appeal with your plan and concurrently an Expedited External Review through the Department of Insurance.
If you are a participant or beneficiary of an employee welfare benefit plan under ERISA, you may have the right to bring a civil action under ERISA Section 502(a) after exhausting the appeals process. Please see your Member Handbook for a complete statement of your rights.
Resources Available to Help You
Need help understanding this notice or our decision? Call us free of charge via the toll-free number on your medical ID card. There are also other resources available to help you.
If you are hearing impaired, you may call TTY: 711 – Telecommunications Relay Service, or call the toll free TDD number 1-800-346-4128.
Your Rights and Protections Against Surprise Medical Bills
When you get emergency care or are treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from balance billing.
What is “balance billing” (sometimes called “surprise billing”)?
When you see a doctor or other health care provider, you may owe certain out-of-pocket costs, like a copayment, coinsurance, or deductible. You may have additional costs or have to pay the entire bill if you see a provider or visit a health care facility that isn’t in your health plan’s network.
“Out-of-network” means providers and facilities that haven’t signed a contract with your health plan to provide services. Out-of-network providers may be allowed to bill you for the difference between what your plan pays and the full amount charged for a service. This is called “balance billing.” This amount is likely more than in-network costs for the same service and might not count toward your plan’s deductible or annual out-of-pocket limit.
“Surprise billing” is an unexpected balance bill. This can happen when you can’t control who is involved in your care—like when you have an emergency or when you schedule a visit at an innetwork facility but are unexpectedly treated by an out-of-network provider.
You’re protected from balance billing for:
Emergency services
If you have an emergency medical condition and get emergency services from an out-of-network provider or facility, the most the provider or facility may bill you is your plan’s in-network cost-sharing amount (such as copayments and coinsurance). You can’t be balance billed for these emergency services. This includes services you may get after you’re in stable condition, unless you give written consent and give up your protections not to be balanced billed for these post-stabilization services.
Certain Services at an In-network Hospital or Ambulatory Surgical Center
When you get services from an in-network hospital or ambulatory surgical center, certain providers there may be out-of-network. In these cases, the most those providers may bill you is your plan’s in-network cost-sharing amount. This applies to emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services. These providers can’t balance bill you and may not ask you to give up your protections not to be balance billed.
If you get other services at these in-network facilities, out-of-network providers can’t balance bill you, unless you give written consent and give up your protections.
You’re never required to give up your protections from balance billing. You also aren’t required to get out-of-network care. You can choose a provider or facility in your plan’s network.
When balance billing isn’t allowed, you also have these protections:
- You are only responsible for paying your share of the cost (like the copayments, coinsurance, and deductibles that you would pay if the provider or facility was in-network).
- Your health plan generally must:
- Cover emergency services without requiring you to get approval for services in advance (also known as “prior authorization”).
- Cover emergency services by out-of-network providers.
- Base what you owe the provider or facility (cost-sharing) on what it would pay an in-network provider or facility and show that amount in your explanation of benefits.
- Count any amount you pay for emergency services or out-of-network services toward your in-network deductible and out-of-pocket limit.
If you think you’ve been wrongly billed, you may contact the No Surprises Help Desk (NSHD) at 1-800-985-6059 or visit https://www.cms.gov/nosurprises for more information on your protections under federal law.
