Department of Public Health and Human Services

Montana Healthcare Programs Provider Information » Physician

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Provider Manuals

General Information for Providers 02/2017

Medicaid manual with general information for all provider types. 

Physician-Related Services 11/2016

This manual has information specific to your provider type.

Prescription Drug Program 12/2016

This manual has information specific to your provider type.

Mental Health Services – Adult 03/2017

This manual has information specific to your provider type.

Mental Health Services – Children 10/2015

See the CMHB section of the Plans and Publications page on the DPHHS website.

Passport to Health 11/2015

Everything a provider needs to know to become a successful Passport provider.

Prescription Drug Program 11/2016

This manual has information specific to your provider type.

Provider Manuals – Replacement Pages

General Information for Providers

02/06/2017 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.
09/12/2016 In summary, the entire manual has undergone formatting changes, the Billing Procedures section has had some minor
language changes and the Cover reflects the current date.





General Information For Providers, July 2016

01.19.2016 General Information for Providers, January 2016: Introduction Regarding HELP Plan Information
01.15.2016 General Information for Providers, January 2016: Introduction Regarding HELP Plan Information
12.31.2015 General Information for Providers, January 2016: HELP Plan-Related Updates and Others
07.31.2015 General Information for Providers, August 2015: Entire Manual
11.19.2014 General Information for Providers, November 2014:Billing Procedures
10.08.2014 General Information for Providers, October 2014: Billing Procedures
07.22.2014 General Information for Providers, July 2014:Member Eligibility and Responsibilities
06.30.2014 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.
04.13.2012 General Information for Providers, April 2012: Medicaid Covered Services and Client Eligibility
04.29.2005 General Information for Providers, April 2005: Member Number a Billable Number and Key Contacts Updated
11.05.2004 General Information for Providers, November 2004: References to Medicaid Rules and Regulations Added
09.16.2004 General Information for Providers, September 2014: Team Care and Nurse First Information Added

Physician-Related Services

11/28/2016 In summary, the Page 5.6 of the Billing Procedures chapter was amended to add information for locum tenens, several links were updated, and two blank pages were removed. The Table of Contents and Index sections were adjusted, several links were updated in the Introduction and Covered Services Chapter, the entire manual was formatted as approved by the September 2016 Manuals Meeting for initial 508 adaptations, and the Cover page was amended with the current date.

09/12/2016 In summary, the entire manual has undergone formatting changes, the Billing Procedures section has had some minor language changes and the Cover reflects the current date.

08.31.2016 In summary, The cost share section was removed from the Billing Procedures Chapter, related entries were removed from the Index Section adjustments were made to the Index Section , and the date was changed on the Cover Page.

07.31.2015 Physician-Related Services, August 2015: Entire Manual

07.08.2014 Physician-Related Services, July 2014: Multiple Chapters

03.14.2008 Physician-Related Services, March 2008: Key Contacts, Completing a Claim Form, Prior Authorization, Billing for Immunizations

07.25.2006 Physician-Related Services, July 2006: Well-Child EPSDT Update

04.25.2006 Physician-Related Services, April 2006: Revised Instructions for Completing a Claim, Revised Information on How Cost-Sharing Affects Claim Payment

01.05.2006 Physician-Related Services, September 2005: New EPSDT, Hysterectomy Acknowledgement Form, Revised Information on Imaging Modifiers, Billing for Immunizations, and ER Visits for Clients under Age 2

03.01.2005 Physician-Related Services, March 2005: Hysterectomy Acknowledgement Update

01.25.2005 Physician-Related Services, January 2005: Rule References Added, Updates to Covered Services, PA and Modifiers

11.16.2004 Physician-Related Services, November 2004: Updated Prescription Drug PA Criteria

09.15.2004 Physician-Related Services, September 2004: Team Care Added

06.16.2004 Physician-Related Services, July 2004: Clarification on Sterilizations, Hysterectomies, Abortions and HIPAA and Drug PA Update

12.23.2003 Physician-Related Services, December 2003: Immunizations, PA Criteria, Family Planning, and Using Modifiers

09.16.2003 Physician-Related Services, September 2003: Hysterectomies and Prescription Drug PA Update

08.20.2003 Physician-Related Services, June 2003: New Emergency Services Policy and Hard Card Information

07.28.2003 Physician-Related Services, August 2003: Hysterectomy Requirements

06.01.2003 Physician-Related Services, June 2003: New PA Requirements and Hysterectomy Information

01.02.2003 Physician-Related Services, January 2003: Prior Authorization

09.01.2002 Physician-Related Services, September 2002: Cost Sharing

Prescription Drug Program

12/27/2016 In summary, the Cost Share section of the Billing Procedures chapter was updated and the Cover Page was updated with the current date.

11/15/2016 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

06.27.2016 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.

06.15.2016 Prescription Drug Program, July 2016: Cost Share Updates

12.31.2015 Prescription Drug Program, January 2016: HELP Plan-Related Updates and Others

07.21.2015 Prescription Drug Program, Prior Authorization, Reimbursement, and Billing Procedures

03.25.2015 Prescription Drug Program, Entire Manual

09.27.2013 Prescription Drug Program, Reimbursement

09.05.2013 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).

04.17.2013 Prescription Drug Program, Key Contacts and Reimbursement

02.04.2013 Prescription Drug Program, Medicaid Covered Products

02.01.2012 Prescription Drug Program, Multiple Chapters

09.01.2011 Prescription Drug Program, Medicaid Covered Services and Reimbursement (Dispensing Fee) and MHSP Covered Products (Formulary Drugs)

06.17.2011 Prescription Drug Program
Entire manual has changed from last posted version.

11.16.2004 Prescription Drug Program, Updated Prescription Drug Prior Authorization Criteria

06.16.2004 Prescription Drug Program, Prior Authorization and HIPAA Updates

06.10.2004 Prior Authorization Additions

Mental Health - Adult


03/16/2017 In summary, some minor changes were made to language on the code chart on page 10.

08.25.2016 In Summary, the Cost Share section on pages 4 and 5 was removed and replaced with a referral to the general manual, and the index was adjusted to reflect impacted page numbers.

06.08.2016 Mental Health - Adult July 2016 In summary, the Cover Page date was changed and the Index was amended to replace  “Basic” and “Full” Medicaid to “Standard Medicaid”

Passport to Health

11.09.2015 Passport to Health, November 2015: Passport Referrals

Medicaid Rules and Regulations

Fee Schedules – Physician

01/09/2017 PDF January 2017 Physician Rev.01/13/2017 Excel January 2017 Physician Rev.01/13/2017
07/2016 PDF July 2016 Physician Rev. 09/13/2016 Excel July 2016 Physician Rev. 09/13/2016
01/18/2016 PDFJanuary 2016 Physician Rev. 03/24/2016 Excel January 2016 Physician Rev. 03/242016
08/04/2015 PDF July 2015 Physician Rev. Excel July 2015 Physician Rev.
04/16/2015  PDF January 2015 Physician Rev. ExcelJanuary 2015 Physician Rev.
07/2014  PDF July 2014 Physician Rev. Excel July 2014 Physician Rev.
02/2014 PDF January 2014 Physician Rev. Excel January 2014 Physician Rev.

Fee Schedules – 72-Hour Presumptive

Fee Schedules – ATP Tests and Fees

01/17/2017  PDF January 2017 ATP  EXCEL January 2017 ATP
12/24/2015 January 2016 ATP  
01/2015 January 2015 ATP  
01/2014 January 2014 ATP      

Fee Schedule - Medicaid Mental Health Adults 18 and Over

Fee Schedule - Medicaid Mental Health Youth Under 18

Fee Schedule - Mental Health Services Plan (MHSP) Adults 18 and Over

Mental Health Services Plan (MHSP) Adults 18 and Over

07/01/2016 July 2016 MHSP for Adults

12/17/2015 January 2016 MHSP for Adults Rev. 12/24/2015

07/2015 July 2015 MHSP for Adults

07/2014 July 2014 MHSP for Adults




Fee Schedule - Mental Health Services Plan (MHSP) Youth Under 18

Mental Health Services Plan (MHSP) Youth Under 18

06/08/2016 July 2016 Medicaid Mental Health for Youth

Provider Notices

For prescription medication notices, see the Pharmacy page/


05/26/2017 Federal Final Rule, "Nondiscrimination in Health Program and Activities” and Implication for Coverage of Services Related to Gender Transition
05/01/2017 Vaccine Administration Code Update
04/24/2017 Unlisted Services or Procedures Reminder
04/21/2017 Bowel Management Program Supplies
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
04/05/2017 New Form to Document Need for Orthognathic Surgery
04/04/2017 PA Criteria for Artificial Disc Replacement
04/04/2017 Criteria for Orthognathic Surgery
04/04/2017 Changes to Medical Surgical PA
04/04/2017 Criteria for Panniculectomy
03/31/2017  Ketone Test Strips - A4250 & A252
03/16/2017  Physician Administered Drugs - Update
03/07/2017  Reminder: Billing for Services in ASCs
02/07/2017 New Place of Service for Telehealth
01/13/2017 Update to January 2017 Fee Schedules
01/13/2016 Audiology Referrals and Physician Authorization for Hearing Aids
02/02/2017 EPSDT ( Children's) Lead Screening Requirements


12/08/2016 Physician Administered Drugs - Local Anesthetics
11/30/2016 EnLyte®
11/21/2016 Humira Unit Submission 1
1/21/2016 PA for Methadone
11/10/2016 Vaccines For Children Administration Update
11/03/2016 Smart PA® for Synagis® Revised 11/15/2016
09/27/2016 Physician Administered Drugs - NDC Requirements Revised
09/26/2016 Coverage of Weighted Blankets
09/22/2016 Physician Administered Drugs Update - NDC Requirements
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
07/12/2016 Vaccine Administration Code Update
07/05/2016 PA For Botox No Longer Required
07/05/2016 Circumcision Prior Authorization Changes
05/19/2016 Changes to Member Cost Share
05/10/2016 PRTF Ancillary Services
04/07/2016 Montana Plan First - IUD and Anesthesia Updates
04/06/2016 Hepatitis C Prior Authorization Streamlined Request Form
04/05/2016 Place of Service Code Change
02/19/2016 Physician Fee Schedule Update
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 Increase in Passport Caseloads Due to HELP Plan
12/30/2015 Addictive and Mental Disorders Division Changes to Prior Authorization
11/27/2015 Compound Drugs Billed on CMS-1500
11/23/2015 Prior Authorization Requests and Medical-Surgical Prior Authorization Request Form Rev. 12/2015
11/13/2015 Oral Nutrition for Children Under Age 21 – EPSDT
11/03/2015 Services Exempt from Passport to Health Referral
10/21/2015 SmartPA® Prior Authorization for Synagis®
10/09/2015 Montana Plan First – ICD-10 Update
10/07/2015 Compound Drugs Billed on CMS-1500
10/01/2015 Changes to the Children's Mental Health Bureau Medicaid Services Provider Manual
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
07/21/2015 Discarded Drugs and Biologicals and the Use of the JW Modifier
07/08/2015 Montana Plan First – Revised List of Plan First Covered Services
06/24/2015 Primary Care Enhanced Payment Program Ends
06/19/2015 Vaccine Administration Code Update
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
03/25/2015 EFT for Passport Providers
03/11/2015 Criteria for Breast Reconstruction
03/11/2015 Criteria for Prophylactic Mastectomy
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
12/10/2014 Primary Care Enhanced Payment Extended
12/01/2014 Billing and Code Clarification for Individual and Family Therapy on the Same Day
11/24/2014 DME Order and Prescription Requirements
10/08/2014 Vaccine Administration Code Update
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
08/05/2014 Montana Prescription Drug Registry
06/25/2014 Elective Deliveries – Mid-Level Practitioners and Physicians
06/12/2014 ICD-10 Delay
06/06/2014 Changes to Prior Approval Requirement for Makena (Code J1725)
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 Vaccine Administration Code Update
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

Other Resources

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.

Lab Panels 2007 01/2007
List of codes that make up lab panels for 2004–2007

Notice for Surgery Following Mastectomy 11/2003
All health plans that cover mastectomies must also cover reconstructive surgery.

Plan First Medicaid Non-Covered Agreement 07/2012

Prior Authorization Criteria for Specific Services

Rebateable Manufacturers 04/2017

SURS Provider Self-Audit Protocol 10/2015


To locate older documents, access the Archive Page.