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Provider Manuals

General Information for Providers 02/2017

Medicaid manual with general information for all provider types.

Prescription Drug Program 12/2016

This manual has information specific to your provider type.

Provider Manuals – Replacement Pages

General Information for Providers


In summary, the Telemedicine Chapter was added as a new chapter.  And the Medically Needy section of the Member Responsibilities Chapter page 6.5 was updated.



General Information For Providers, July 2016


General Information for Providers, January 2016: Introduction Regarding HELP Plan Information


General Information for Providers, January 2016: Introduction Regarding HELP Plan Information


General Information for Providers, January 2016: HELP Plan-Related Updates and Others


General Information for Providers, November 2015: Billing Procedures, Revenue Codes 25X and 27X


General Information for Providers, August 2015: Entire Manual


General Information for Providers, November 2014: Billing Procedures


General Information for Providers, September 2014: Billing Procedures


General Information for Providers, June 2014: Member Eligibility and Responsibilities, Presumptive Eligibility


General Information for Providers, June 2014: Entire Manual
If information is found on the website, it has been removed from the manual, and a link to the source is provided.


General Information for Providers: Medicaid Covered Services and Client Eligibility

Prescription Drug Program


In summary, the Cost Share section of the Billing Procedures chapter was updated and the Cover Page was updated with the current date.


In summary, the Reimbursement Chapter has some revised language changes, the whole Prescription Drug Manual has been reformatted with changes approved for all manuals in September 2016, and the Cover page was updated with the most recent modification date


Prescription Drug Program, July 2016: In summary, the Reimbursement for Covered Drugs and FMAC were modified, Average Acquisition Cost and Submitted Ingredient Cost sections were added, and the Estimated Acquisition Cost section was removed from Chapter 6, Reimbursement. The Table of Contents was updated and the Cover Page was amended to reflect the effective date.


Prescription Drug Program, July 2016: Cost Share Updates


Prescription Drug Program, January 2016: HELP Plan-Related Updates and Others


Prescription Drug Program, Prior Authorization, Reimbursement, and Billing Procedures


Prescription Drug Program, Entire Manual


Prescription Drug Program, Reimbursement


Prescription Drug Program, Entire Manual Including the New Passport Chapter
This set of replacement pages contains a terminology change ("client" to "member"); however, only content changes are marked with a change bar (black line).


Prescription Drug Program, Key Contacts and Reimbursement


Prescription Drug Program, Medicaid Covered Products


Prescription Drug Program, Multiple Chapters


Prescription Drug Program, Medicaid Covered Services and Reimbursement (Dispensing Fee) and MHSP Covered Products (Formulary Drugs)


Prescription Drug Program
Entire manual has changed from last posted version.


Prescription Drug Program, Updated Prescription Drug Prior Authorization Criteria


Prescription Drug Program, Prior Authorization and HIPAA Updates


Prior Authorization Additions

Preferred Drug Information

Preferred Drug List  Rev. 06/09/2017

List of preferred drugs and other preferred drug list information.

Evidence-Based Medicine Documentation

Resources used by the Montana Formulary Committee members come from the OHSU Drug Effectiveness Review Project which can be accessed through this link.

Average Acquisition Cost Links

Provider Notices


05/26/2017 Federal Final Rule, "Nondiscrimination in Health Program and Activities” and Implication for Coverage of Services Related to Gender Transition
05/15/2017  2017 Average Acquisition Cost (AAC) Survey
05/09/2017  2017 Annual Montana Dispensing Fee Survey
04/20/2017  Plan First Hysterectomy codes added effective April 1, 2017
04/11/2017  Medication Authorization Changes
04/06/2017 New EPSDT Request Form
03/31/2017  Ketone Test Strips - A4250 & A252


11/30/2016 EnLyte®
11/21/2016 Humira Unit Submission
11/21/2016 PA for Methadone
11/03/2016 Smart PA® for Synagis® Revised 11/15/2016
09/26/2016 Coverage of Weighted Blankets
08/12/2016 Vaccine Administration by Pharmacists
08/12/2016 Removal of 15-day Supply Limit on Initial Atypical Antipsychotic Prescriptions
07/28/2016 Montana Plan First Preventive Code Additions
07/18/2016 Changes to Member Cost Share Update
06/27/2016 Reverse and Rebill for Drug Cost Disputes
06/27/2016 Average Acquisition Cost Reimbursement Methodology
05/19/2016 Changes to Member Cost Share
04/06/2016 Hepatitis C Prior Authorization Streamlined Request Form
03/04/2016 Vaccine Administration by Pharmacists for Adolescents Age 12-18 Years
02/01/2016 Basic Medicaid Benefit Increased to Standard Medicaid Benefit
01/15/2016 Standard Medicaid and HELP Plan Claims Processing Rev. 01/19/2016
01/15/2016 Hospital Grade Electric Breast Pump Requirements


12/31/2015 Changes to Montana Medicaid
12/31/2015 Montana HELP Plan
11/30/2015 New Montana Medicaid Pharmacy Claims Processing System
11/13/2015 Oral Nutrition for Children Under Age 21 – EPSDT
11/03/2015 Pharmacy Provider License Status
11/03/2015 Services Exempt from Passport to Health Referral
10/21/2015 SmartPA® Prior Authorization for Synagis®
10/09/2015 Plan First Prescriptions and ICD-10
10/09/2015 Montana Plan First – ICD-10 Update
10/01/2015 Changes to the Children's Mental Health Bureau Medicaid Services Provider Manual
09/25/2015 2015 Annual Montana Dispensing Fee Survey
08/03/2015 ICD-10 Guidance for Implementing International Classification of Diseases, 10th Edition (ICD-10)
07/31/2015 Adult and Pediatric Specialty Table of Services Available in Montana
7/08/2015 Montana Plan First – Revised List of Plan First Covered Services
06/09/2015 National Drug Code (NDC) Billing
05/07/2015 Anesthesia and Global Service Requirement
05/06/2015 Prior Authorization Required for Jublia® Topical Solution
03/27/2015 Initial Prescription Fill Requirements for Attention Deficit Hyperactive Disorder Stimulant Drugs
02/23/2015 New Restrictions Added to Hydrocodone-Chlorpheniramine Suspension (Tussionex®)
02/11/2015 New HCPCS Modifiers – XE, XP, XS, and XU


12/18/2014 Electronic Funds Transfer (EFT) and Electronic Remittance Advice (ERA) Changes Final Notice
11/24/2014 Pharmacy Provider License Status
11/24/2014 DME Order and Prescription Requirements
10/27/2014 Prior Authorization Criteria for Hepatitis C Treatments   All PA forms for Hepatitis C Treatments are now in the Forms section of the website as of 03/21/2016
10/20/2014 SmartPA® Prior Authorization for Synagis®
10/01/2014 Prior Authorization Required for the Antibiotic Sivextro® and the New Antifungal Luzu®
09/22/2014 Provider Atypical Anti Psychotics for Children Ages Six and Under – Prior Authorization Requirement
09/17/2014 2014 Annual Montana Dispensing Fee Survey
09/16/2014 Adoption of the New Children's Mental Health Bureau's Medicaid Provider Manual into Administrative Rules of Montana
08/22/2014 Tobacco Cessation Products
08/13/2014 Multisource Preferred Brand Name Products
08/05/2014 Montana Prescription Drug Registry
06/30/2014 Dispensing Fee Increase
06/12/2014 ICD-10 Delay
06/06/2014 SmartPA Quantity Limit for Oxycodone
05/13/2014 PERM Provider Educational Webinars
04/22/2014 Modifier Changes for Professional Claim Billers
03/18/2014 Information Regarding CMS-1500
01/29/2014 Centers for Medicare and Medicaid Services (CMS) ICD-10 Provider Readiness Assessment Update
01/28/2014 SmartPA® Prior Authorization for All Preparations to Treat Head Lice
01/28/2014 Prior Authorization for Zubsolv®
01/09/2014 Using Medicaid Card ID Number When Billing and Checking Eligibility
01/09/2014 Reimbursement Changes for Covered Ancillary Services Provided to Youth in a PRTF and Additional Information Pertaining to PRTF Services

Drug Use Review (DUR) Board

Montana Drug Use Review (DUR) Board / Formulary Committee

Notification of upcoming meetings for drug use review, agendas, related meeting information, and minutes from past meetings.

Drug Use Review Board

Information on the Medicaid Drug Use Review Board.

Medicaid Rules and Regulations

MHSP Information

08/31/2015 MHSP Formulary Rev.

08/27/2015 MHSP Preferred Manufacturers 07/2015

Other Resources

Dispensing Fee Questionnaire 09/2015

EOB R&R Crosswalk PDF and EOB R&R Crosswalk Excel 02/2011
With the implementation of HIPAA, Medicaid discontinued the use of Medicaid EOB codes and began using HIPAA standard reason and remark (R&R) codes. This document crosswalks the HIPAA standard R&R codes to the Medicaid EOB codes.

NCPDP D.0 Payer Sheet 06/2017

Plan First Medicaid Non-Covered Agreement 07/2012

Rebateable Manufacturers 04/2017

SURS Provider Self-Audit Protocol 10/2015

To locate older documents, access the Archive Page.