PacificSource Health Plans claim denials in Montana: the federal figures
PacificSource Health Plans denied 3.7% of in-network claims in Montana — 15,272 claims out of 410,171. Here is what happened to the people who appealed.
What happened to appeals
| Stage | Filed | Overturned |
|---|---|---|
| Internal appeal (to PacificSource Health Plans) | 1,977 | 77.4% |
| External review (independent) | 13 | — |
What PacificSource Health Plans denies most
The most common denial reason recorded for PacificSource Health Plans plans in Montana is administrative reason. How that denial is beaten →
| Denial reason | Claims | Share |
|---|---|---|
| Administrative reason | 11,702 | 34.3% |
| Member not covered | 8,217 | 24.1% |
| Benefit limit reached | 8,147 | 23.9% |
| Service excluded from the plan | 3,039 | 8.9% |
| Other reasons | 1,206 | 3.5% |
| Referral required | 1,052 | 3.1% |
| Experimental or investigational | 740 | 2.2% |
| Provider out of network | 48 | 0.1% |
What to do if PacificSource Health Plans denied your claim
- Get the reason in writing. The denial notice must state the specific reason and the plan provision behind it. If it does not, request it — you are entitled to it free of charge.
- File the internal appeal. Generally within 180 days of the denial notice. PacificSource Health Plans overturned 77.4% of the internal appeals it received.
- If they say no again, go external. An independent organization reviews it — not PacificSource Health Plans. Generally you have 4 months from the final internal denial. This is the step nearly everyone skips.
- Ask for expedited review if waiting would seriously jeopardise your health. That timeline is days, not months.
Everything you need for your PacificSource Health Plans appeal: your two deadlines, the argument that fits your denial reason, an evidence checklist, and the external review request. Opens on screen the moment you pay.
Questions
Is PacificSource Health Plans's denial rate high?
3.7% against a national average of 16% across the plans in this dataset. It is at or below average. A denial rate describes the insurer, not the merits of your claim.
Does appealing cost anything?
The internal appeal is free. External review is free under the HHS-administered federal process; where an issuer uses a contracted independent review organization or a state process, any fee is capped at $25.
Can PacificSource Health Plans ignore the external decision?
No. External review decisions are binding on the plan.