Prior authorization refers to services that require Department authorization before they are performed. Prior authorization has specific requirements. Some services may require both Passport referral and prior authorization. If a service requires prior authorization, the requirement exists for all Medicaid members. Prior authorization is usually obtained through the Department or a prior authorization contractor.
Cervical
Lumbar
MPQH
Phone
(406) 457-3060 Local
(877) 443-4021 Long‑distance
Fax
(406) 513-1923 Local
(877) 443-2580 Long‑distance
Reconstructive blepharoplasty may be covered for:
Documentation must include:
MPQH Call Center:
(406) 443-0320 (Helena) or
(800) 219-7035 (Toll Free)
BRCA screening is allowed in the following instances:
• Members is over the age of 18; and
• Have at least one of the following criteria:
o Personal history of any of the following:
♦ Breast cancer diagnosis at or before age 45.
♦ Breast cancer diagnosis at or before age 50 with any of the following:
♦ An additional breast cancer primary;
• 1 or more close blood relative with breast cancer at any age;
• 1 or more close blood relative with pancreatic cancer;
• 1 or more close blood relative with prostate cancer with a Gleason score ≥7.
♦ Breast cancer diagnosis at or before age 60 with:
• Triple negative breast cancer.
♦ Breast cancer diagnosis at any age with any of the following:
• 1 or more close relatives with breast cancer diagnosed before age 50;
• 2 or more close blood relatives with breast cancer diagnosis at any age;
• 1 or more close blood relative with ovarian cancer diagnosis;
• 2 or more close blood relatives with pancreatic cancer diagnosis or prostate cancer diagnosis with a Gleason score ≥7;
• 1 or more close blood relative diagnosed with male breast cancer.
♦ Male breast cancer diagnosis at any age.
♦ Ovarian cancer diagnosis at any age.
♦ Fallopian tube cancer diagnosis at any age.
♦ Primary peritoneal cancer diagnosis at any age.
♦ Prostate cancer diagnosis with a Gleason score 7 at any age with any of the following:
• 1 or more close blood relative with ovarian cancer at any age;
• 1 or more close blood relative with breast cancer before age 50;
• 2 or more close blood relatives with breast,pancreatic, or prostate cancer (Gleason score ≥7) at any age.
♦ Pancreatic cancer diagnosis at any age with any of the following:
• Ashkenazi Jewish ancestry;
• 1 or more close blood relative with ovarian cancer at any age;
• 1 or more close blood relative with breast cancer before age SO;
• 2 or more close blood relatives with breast,pancreatic,or prostate cancer (Gleason score ≥7) at any age.
o Family history of any of the following:
♦ First or second degree blood relative who meet any of the above criteria.
♦ Third degree blood relative who has breast cancer and/or ovarian cancer and who has 2 or more close blood relatives with breast cancer (at least one with breast cancer before age SO) and/or ovarian cancer.
♦ 1 or more family member with a known potentially harmful mutation In the BRCAl or BRCA2 gene.
*Close blood relative includes first, second,and third degree relatives on the same side of the family.
**Breast cancer diagnosis includes invasive and ductal carcinoma in situ.
MPQH Call Center:
(406) 443-0320 (Helena) or
(800) 219-7035 (Toll Free)
Criteria for Breast Reconstruction rev. 03/21/2018
MPQH Call Center:
(406) 443-0320 (Helena) or
(800) 219-7035 (Toll Free)
Cochlear implants may be covered for:
Adult Criteria
Pediatric Criteria
Documentation Must Include
Replacements
Components of the Cochlear Implant may be replaced no more than once in a five-year period and only if:
MPQH Call Center:
(406) 443-0320 (Helena) or
(800) 219-7035 (Toll Free)
See the Orthodontia Prior Authorization 06/2023
EPSDT Prior Authorization and Certification of Medical Necessity Form 06/2023
Medical necessity documentation must include all of the following:
For members being treated by a licensed therapist, a copy of the member’s plan of care in relation to the item/service is required; video if possible.
MPQH Call Center:
(406) 443-0320 (Helena) or
(800) 219-7035 (Toll Free)
MPQH Call Center:
(406) 443-0320 (Helena) or
(800) 219-7035 (Toll Free)
Medical necessity documentation must include all of the following:
Health Policy and Services Division
Medicaid Services Bureau
DPHHS
P.O. Box 202951
Helena, MT 59620-2951
(406) 444-1861 Fax
Surgical services are only covered when done to restore physical function or to correct physical problems resulting from:
Documentation requirements include a letter from the attending physician documenting:
MPQH Call Center:
(406) 443-0320 (Helena) or
(800) 219-7035 (Toll Free)
Required information includes:
MPQH Call Center:
(406) 443-0320 (Helena) or
(800) 219-7035 (Toll Free)
For information on prior authorization required for youth mental health services, please refer to the CMHB Medicaid Services Provider Manual on the Manuals and Guides webpage.
MPQH Call Center:
(406) 443-0320 (Helena) or
(800) 219-7035 (Toll Free)
To submit PA requests, see the Document Library tab on the Mountain-Pacific Quality Health Medicaid Portal.
MPQH Call Center:
(406) 443-0320 (Helena) or
(800) 219-7035 (Toll Free)
Pharmacy Preferred Drug Information can be found here: 19 (mt.gov)
Prior Authorization Criteria and required forms can be found here:
Mountain-Pacific Quality Health – Medicaid Pharmacy (mpqhf.org)
Instructions for Physician Administered Drug Prior Authorization:
Reminders:
Drugs with specific criteria sets:
Aduhelm (aducanumab-avwa)Referring physician and surgeon must submit documentation.
Back pain must have been documented and present for at least 6 months, and causes other than weight of breasts must have been excluded.
Indications for female member
Documentation in the member’s record must indicate/support:
Height Weight of Tissue per Breast
<5' 250 grams
5' - 5'2" 350 grams
5'2" - 5'4" 450 grams
>5'4" 500 grams
Indications for male member:
MPQH Call Center:
(406) 443-0320 (Helena) or
(800) 219-7035 (Toll Free)
Montana Medicaid requires prior authorization for pulmonary and cardiac rehabilitation and for out-of-state inpatient rehabilitation.
Documentation Requirements
Required information includes:
Prior Authorization Contact
MPQH Call Center:
(406) 443-0320 (Helena) or
(800) 219-7035 (Toll Free)
The following do not require prior authorization:
Medicaid covers rhinoplasty in the following circumstances:
Medicaid does not cover rhinoplasty or septoplasty in the following circumstances:
Documentation requirements include a letter from the attending physician documenting:
MPQH Call Center:
(406) 443-0320 (Helena) or
(800) 219-7035 (Toll Free)
Nonsurgical treatment for TMJ disorders must be utilized first to restore comfort, and improve jaw function to an acceptable level. Non-surgical treatment may include the following in any combination depending on the case:
Surgical treatment may be considered when both of the following apply:
Not covered:
MPQH Call Center:
(406) 443-0320 (Helena) or
(800) 219-7035 (Toll Free)
Required information includes:
MPQH Call Center:
(406) 443-0320 (Helena) or
(800) 219-7035 (Toll Free)
Required information includes:
MPQH
Phone
Local
(406) 443-6100
(800) 292-7114
Fax
Local
(406) 443-0684
Long-distance
(800) 291-7791