Department of Public Health and Human Services

Montana Healthcare Programs Provider Information » Hospital Outpatient

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Hospital Outpatient

Hospital Outpatient

Provider Manuals

General Information for Providers  09/2017
Medicaid manual with general information for all provider types.
Hospital Outpatient Services 10/2017
This manual has information specific to your provider type.
Critical Access Hospitals 09/2017
This manual has information specific to critical access hospitals.
Passport to Health 10/2017
Everything a provider needs to know to become a successful Passport provider
Rebateable Manufacturers 10/2017

 

 

Medicaid Rules and Regulations

Fee Schedules – APC

Some documents on this page are legal and/or historical in nature and cannot be altered to meet 508 Accessibility standards.  Each of those documents has a corresponding .txt document with the same name placed next to it.

October 2017

PDF: October 2017 APC Services Fee Schedule Cover Sheet Cover Sheet October 2017 APC Services Fee Schedule
Excel: October 2017 APC Services Fee Schedule

July 2017

PDF: July 2017 APC Cover Sheet   July 2017 APC Fee Schedule PDF 
Excel: July 2017 APC Fee Schedule Excel

April 2017

PDF: April 2017 APC Cover Sheet   April 2017 APC Fee Schedule PDF
Excel: April 2017 APC Fee Schedule Excel

January 2017

PDF: January 2017 APC
Excel: January 2017 APC
TXT: January 2017 APC

October 2016

PDF:  October 2016 APC
ExcelOctober 2016 APC
TXT: October 2016 APC

July 2016

PDF: July 2016 APC
Excel:  July 2016 APC
TXT: July 2016 APC

April 2016

PDF: April 2016 APC 
Excel: April 2016 APC
TXT: April 2016 APC

January 2016

PDF: January 2016 APC Rev 04/26/2016
Excel: January 2016 APC Rev 04/26/2016
TXT: January 2016 APC Rev 04/26/2016

October 2015

PDF: October 2015 APC
Excel: October 2015 APC
TXT: October 2015 APC

July 2015

PDF: July 2015 APC
Excel: July 2015 APC
TXT: July 2015 APC

April 2015

PDF: April 2015 APC 
Excel: April 2015 APC
TXT: April 2015 APC

January 2015

PDF: January 2015 APC
Excel: January 2015 APC
TXT: January 2015 APC

Fee Schedules – ATP Tests and Fees

Some documents on this page are legal and/or historical in nature and cannot be altered to meet 508 Accessibility standards.  Each of those documents has a corresponding .txt document with the same name placed next to it.

January 2017

PDF: January 2017 ATP  
Excel: January 2017 ATP
TXT: January 2017 ATP

January 2016

PDF: January 2016 ATP  
TXT: January 2016 ATP

January 2015

PDF: January 2015 ATP  
TXT: January 2015 ATP

Fee Schedules – Clinical Laboratory (CLAB)

Some documents on this page are legal and/or historical in nature and cannot be altered to meet 508 Accessibility standards.  Each of those documents has a corresponding .txt document with the same name placed next to it.

October 2015

PDF: October 2015 Clinical Laboratory (CLAB)
Excel: October 2015 Clinical Laboratory (CLAB)
TXT: October 2015 Clinical Laboratory (CLAB)

July 2015

PDF: July 2015 Clinical Laboratory (CLAB)
Excel: July 2015 Clinical Laboratory (CLAB)
TXT: July 2015 Clinical Laboratory (CLAB)

April 2015

PDF: April 2015 Clinical Laboratory (CLAB)
Excel: April 2015 Clinical Laboratory (CLAB)
TXT: April 2015 Clinical Laboratory (CLAB)

January 2015

PDF: January 2015 Clinical Laboratory (CLAB)
Excel: January 2015 Clinical Laboratory (CLAB)
TXT: January 2015 Clinical Laboratory (CLAB)

Fee Schedules – Outpatient Procedure (OPP) Codes

Some documents on this page are legal and/or historical in nature and cannot be altered to meet 508 Accessibility standards.  Each of those documents has a corresponding .txt document with the same name placed next to it.

October 2017

Cover Sheet Cover Sheet October 2017 OPPS Services Fee Schedule  PDF: October 2017 OPPS Services Fee Schedule rev. 11/14/2017
Excel: October 2017 OPPS Services Fee Schedule rev. 11/15/2017

July 2017

PDF: July 2017 OPP Cover Sheet Rev 09/28/2017  July 2017 OPP Fee Schedule PDF rev. 11/14/2017
Excel: July 2017 OPP Fee Schedule Excel rev. 11/14/2017

PDF: April 2017 OPP Cover Sheet     April 2017 OPP Fee Schedule PDF    rev. 11/14/2017
Excel: April 2017 OPP Fee Schedule Excel rev. 11/14/2017

January 2017

PDF: January 2017 OPP Codes
Excel: January 2017 OPP Codes
TXT: January 2017 OPP Codes

October 2016

PDF: October 2016 OPP Codes
Excel: October 2016 OPP Codes
TXT: October 2016 OPP Codes

July 2016

PDF: July OPP Codes Rev 07/26/2016
Excel:  July OPP Codes Rev 07/26/2016
TXT: July OPP Codes Rev 07/26/2016

April 2016

PDF: April OPP Codes Rev 07/11/2016
Excel: April 2016 OPP Codes  Rev 07/11/2016
TXT: April OPP Codes Rev 07/11/2016

January 2016

PDF: January 2016 OPP Codes Rev 05/12/2016
Excel:  January 2016 OPP Codes Rev 05/12/2016
TXT: January 2016 OPP Codes Rev 05/12/2016

October 2015

PDF: October 2015 OPP Codes Rev 11/2015
Excel: October 2015 OPP Codes Rev 11/2015
TXT: October 2015 OPP Codes Rev 11/2015

July 2015

PDF: July 2015 OPP Codes Rev02/11/2016
Excel: July 2015 OPP Codes Rev 02/11/2016
TXT: July 2015 OPP Codes Rev02/11/2016

April 2015

PDF: April 2015 OPP Codes
Excel: April 2015 OPP Codes
TXT: April 2015 OPP Codes

January 2015

PDF: January 2015 OPP Codes
Excel: January 2015 OPP Codes
TXT: January 2015 OPP Codes

Provider Notices

Some documents on this page are legal and/or historical in nature and cannot be altered to meet 508 Accessibility standards.  Each of those documents has a corresponding .txt document with the same name placed next to it.

2017

11/20/2017 Qualified Medicare Beneficiary (QMB) Claim Adjustments
11/13/2017 Smart PA® Prior Authorization for Synagis®
11/02/2017 New Medicare Card
10/02/2017 Montana Medicaid Expansion Changes
09/25/2017 Vaccine Administration Code Update
09/19/2017 Individual Adjustment Request Form on Split Claims
09/14/2017 Montana Plan First Anesthesia Update
08/21/2017 Clinical Pharmacist Practitioner
08/01/2017 Telemedicine - Correction
07/25/2017 Physician Administered Drugs - Update - NDC Requirements
07/25/2017 Physician Administered Code Update - Procedure Codes Rev. 07/26/2017
05/26/2017 Federal Final Rule, "Nondiscrimination in Health Program and Activities” and Implication for Coverage of Services Related to Gender Transition
07/03/2017 Clinical Pharmacist Practitioner
05/01/2017 Vaccine Administration Code Update
04/24/2017 Unlisted Services or Procedures Reminder
04/20/2017 Plan First Hysterectomy codes added effective April 1, 2017
04/06/2017 New EPSDT Request Form
03/16/2017  Physician Administered Drugs - Update
02/02/2017 EPSDT ( Children's) Lead Screening Requirements
02/02/2017 Change to Medicaid Outpatient Lab Billing

2016

PDF: 12/08/2016 Physician Administered Drugs - Local Anesthetics
TXT:  12/08/2016 Physician Administered Drugs - Local Anesthetics
PDF: 11/03/2016 Smart PA® for Synagis® Revised 11/15/2016
TXT:  11/03/2016 Smart PA® for Synagis® Revised 11/15/2016
PDF: 09/27/2016 Physician Administered Drugs - NDC Requirements Revised
TXT:  09/27/2016 Physician Administered Drugs - NDC Requirements Revised
PDF: 07/28/2016 Montana Plan First Preventive Code Additions
TXT:  07/28/2016 Montana Plan First Preventive Code Additions
PDF: 07/25/2016 Admission Date and Statement Covers Period - Revised
TXT:  07/25/2016 Admission Date and Statement Covers Period - Revised
PDF: 07/18/2016 Changes to Member Cost Share Update
TXT:  07/18/2016 Changes to Member Cost Share Update
PDF: 07/12/2016 Vaccine Administration Code Update
TXT:  07/12/2016 Vaccine Administration Code Update
PDF: 07/05/2016 PA For Botox No Longer Required
TXT:  07/05/2016 PA For Botox No Longer Required
PDF: 07/05/2016 Circumcision Prior Authorization Changes
TXT:  07/05/2016 Circumcision Prior Authorization Changes
PDF: 07/01/2016 Admission Date and Statement Covers Period
TXT:  07/01/2016 Admission Date and Statement Covers Period
PDF: 05/19/2016 Changes to Member Cost Share
TXT:  05/19/2016 Changes to Member Cost Share
PDF: 04/07/2016 Montana Plan First - IUD and Anesthesia Updates
TXT:  04/07/2016 Montana Plan First - IUD and Anesthesia Updates
PDF: 04/05/2016 Place of Service Code Change
TXT:  04/05/2016 Place of Service Code Change
PDF: 03/21/2016 NDC Required for Physician-Administered Drugs: Billing Instructions for Montana Medicaid Crossover Claims
TXT:  03/21/2016 NDC Required for Physician-Administered Drugs: Billing Instructions for Montana Medicaid Crossover Claims
PDF: 03/02/2016 ICD-10 Obstetric Observation Billing Update Revised 03/01/2016
TXT:  03/02/2016 ICD-10 Obstetric Observation Billing Update Revised 03/01/2016
PDF: 02/22/2016 Hospital NDC Billing on Revenue Codes and Electronic Claim Submission Denials
TXT:  02/22/2016 Hospital NDC Billing on Revenue Codes and Electronic Claim Submission Denials
PDF: 02/10/2016 ICD-10 Obstetric Observation Billing Update
TXT:  02/10/2016 ICD-10 Obstetric Observation Billing Update
PDF: 02/01/2016 Basic Medicaid Benefit Increased to Standard Medicaid Benefit
TXT:  02/01/2016 Basic Medicaid Benefit Increased to Standard Medicaid Benefit
PDF: 01/28/2016 LARC Inserted at Time of Delivery in PPS Hospital
TXT:  01/28/2016 LARC Inserted at Time of Delivery in PPS Hospital
PDF: 01/25/2016 Hospital National Drug Code (NDC) Billing on Revenue Codes
TXT:  01/25/2016 Hospital National Drug Code (NDC) Billing on Revenue Codes
PDF: 01/15/2016 Standard Medicaid and HELP Plan Claims Processing Rev/ 01/19/2016
TXT:  01/15/2016 Standard Medicaid and HELP Plan Claims Processing Rev/ 01/19/2016
PDF: 01/15/2016 Hospital Grade Electric Breast Pump Requirements
TXT:  01/15/2016 Hospital Grade Electric Breast Pump Requirements

2015

PDF: 12/31/2015 Changes to Montana Medicaid
TXT:  12/31/2015 Changes to Montana Medicaid
PDF: 12/30/2015 Addictive and Mental Disorders Division Changes to Prior Authorization
TXT:  12/30/2015 Addictive and Mental Disorders Division Changes to Prior Authorization
PDF: 12/09/2015 Increasing Coverage of Lactation Services to Outpatient Hospitals
TXT:  12/09/2015 Increasing Coverage of Lactation Services to Outpatient Hospitals
PDF: 11/23/2015 Prior Authorization Requests and Medical-Surgical Prior Authorization Request Form Rev/ 12/2015
TXT:  11/23/2015 Prior Authorization Requests
PDF: 11/18/2015 Hospital National Drug Code (NDC) Billing on Revenue Codes Rev/ 12/21/2015
TXT:  11/18/2015 Hospital National Drug Code (NDC) Billing on Revenue Codes Rev/ 12/21/2015
PDF: 11/03/2015 Services Exempt from Passport to Health Referral
TXT:  11/03/2015 Services Exempt from Passport to Health Referral
PDF: 10/21/2015 ICD-10 Obstetric Observation Billing
TXT:  10/21/2015 ICD-10 Obstetric Observation Billing
PDF: 10/21/2015 SmartPA® Prior Authorization for Synagis®
TXT:  10/21/2015 SmartPA® Prior Authorization for Synagis®
PDF: 10/09/2015 Montana Plan First – ICD-10 Update
TXT:  10/09/2015 Montana Plan First – ICD-10 Update
PDF: 10/01/2015 Changes to the Children's Mental Health Bureau Medicaid Services Provider Manual
TXT:  10/01/2015 Changes to the Children's Mental Health Bureau Medicaid Services Provider Manual
PDF: 08/19/2015 Identification of Ordering and Referring Providers on UB-04 and 837I X12 Transactions
TXT:  08/19/2015 Identification of Ordering and Referring Providers on UB-04 and 837I X12 Transactions
PDF: 08/17/2015 Medicare Crossover Claims With Medicare Non-Covered Charges That Medicaid Allows
TXT:  08/17/2015 Medicare Crossover Claims With Medicare Non-Covered Charges That Medicaid Allows
PDF: 08/03/2015 ICD-10 Guidance for Implementing International Classification of Diseases, 10th Edition (ICD-10)
TXT:  08/03/2015 ICD-10 Guidance for Implementing International Classification of Diseases, 10th Edition (ICD-10)
PDF: 07/31/2015 Adult and Pediatric Specialty Table of Services Available in Montana
TXT:  07/31/2015 Adult and Pediatric Specialty Table of Services Available in Montana
PDF: 07/21/2015 Discarded Drugs and Biologicals and the Use of the JW Modifier
TXT:  07/21/2015 Discarded Drugs and Biologicals and the Use of the JW Modifier
PDF: 07/08/2015 Montana Plan First – Revised List of Plan First Covered Services
TXT:  07/08/2015 Montana Plan First – Revised List of Plan First Covered Services
PDF: 06/26/2015 Vaccine Administrative Code Update
TXT:  06/26/2015 Vaccine Administrative Code Update
PDF: 06/09/2015 National Drug Code (NDC) Billing
TXT:  06/09/2015 National Drug Code (NDC) Billing
PDF: 03/11/2015 Criteria for Breast Reconstruction
TXT:  03/11/2015 Criteria for Breast Reconstruction
PDF: 03/11/2015 Criteria for Prophylactic Mastectomy
TXT:  03/11/2015 Criteria for Prophylactic Mastectomy
PDF: 02/11/2015 New HCPCS Modifiers – XE, XP, XS, and XU
TXT:  02/11/2015 New HCPCS Modifiers – XE, XP, XS, and XU
PDF: 01/30/2015 Telehealth Diagnosis Codes
TXT:  01/30/2015 Telehealth Diagnosis Codes
PDF: 01/07/2016 Long Acting Reversible Contraception (LARC) Inserted at Time of Delivery in a PPS Hospital
TXT:  01/07/2016 Long Acting Reversible Contraception (LARC) Inserted at Time of Delivery in a PPS Hospital

Other Resources

APR - DRG FAQ

Outpatient Hospital Payment Summary 08/01/2003
Technical specifications for the new hospital outpatient payment method.

Outpatient Prospective Payment System Billing Guide 08/28/2006
PowerPoint Presentation: Outpatient Prospective Billing Guide. If you do not have Microsoft PowerPoint, download PowerPoint Viewer

Prior Authorization Criteria for Specific Services

Rebateable Manufacturers  10/2017

SURS Provider Self-Audit Protocol 1/2015

 

To locate older documents, access the Archive Page.