Hospital Outpatient
General Information for Providers
Medicaid manual with general information for all provider types.
Hospital Outpatient Services
This manual has information specific to your provider type.
Critical Access Hospitals
This manual has information specific to critical access hospitals.
Passport to Health
Everything a provider needs to know to become a successful Passport provider
Rebateable Manufacturers 01/2023
Code of Federal Regulations (Title 42)
Montana Code Annotated - https://leg.mt.gov/ (Choose “Laws & Bills” then “ Montana Statutes – MCA”)
Applicable Section: Title 53, Chapter 6
October 2024 APC Coversheet
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October 2024 APC Fee Schedule Excel
July 2024 APC Coversheet
July 2024 APC Fee Schedule PDF
July 2024 APC Fee Schedule Excel
April 2024 APC Coversheet
April 2024 APC Fee Schedule PDF
April 2024 APC Fee Schedule Excel
January 2024 APC Coversheet
January 2024 APC Fee Schedule PDF
January 2024 APC Fee Schedule Excel
October 2023 APC Coversheet
October 2023 APC Fee Schedule PDF
October 2023 APC Fee Schedule Excel
July 2023 APC Coversheet
July 2023 APC Fee Schedule PDF
July 2023 APC Fee Schedule Excel
April 2023 APC Coversheet
April 2023 APC Fee Schedule PDF
April 2023 APC Fee Schedule Excel
January 2023 APC Coversheet
January 2023 APC Fee Schedule PDF
January 2023 APC Fee Schedule Excel
October 2022 APC Coversheet
October 2022 APC Fee Schedule PDF Rev. 11/18/2022
October 2022 APC Fee Schedule Excel Rev. 11/18/2022
July 2022 APC Coversheet
July 2022 APC Fee Schedule PDF
July 2022 APC Fee Schedule Excel
April 2022 APC Coversheet
April 2022 APC Fee Schedule PDF
April 2022 APC Fee Schedule Excel
January 2022 APC Coversheet
January 2022 APC Fee Schedule PDF
January 2022 APC Fee Schedule Excel
October 2021 APC Coversheet
October 2021 APC Fee Schedule PDF
October 2021 APC Fee Schedule Excel
July 2021 APC Coversheet
July 2021 APC Fee Schedule PDF
July 2021 APC Fee Schedule Excel
April 2021 APC Coversheet
April 2021 APC Fee Schedule PDF
April 2021 APC Fee Schedule Excel
January 2021 APC Coversheet
January 2021 APC Fee Schedule PDF
January 2021 APC Fee Schedule Excel
October 2020 APC Coversheet
October 2020 APC Fee Schedule PDF
October 2020 APC Fee Schedule Excel
July 2020 APC Coversheet
July 2020 APC Fee Schedule PDF rev. 07/22/2020
July 2020 APC Fee Schedule Excel rev. 07/22/2020
April 2020 APC Coversheet
April 2020 APC Fee Schedule PDF
April 2020 APC Fee Schedule Excel
January 2020 APC Coversheet
January 2020 APC Fee Schedule PDF
January 2020 APC Fee Schedule Excel
July 2021 Laboratory Services Coversheet
July 2021 Laboratory Services Fee Schedule PDF
July 2021 Laboratory Services Fee schedule Excel
January 2021 Laboratory Services Coversheet
January 2021 Laboratory Services PDF
January 2021 Laboratory Services Excel
July 2020 Laboratory Services Coversheet
July 2020 Laboratory Services Fee Schedule PDF rev. 08/31/2020
July 2020 Laboratory Services Fee schedule Excel rev. 08/31/2020
January 2020 Laboratory Services Coversheet
January 2020 Laboratory Services PDF
January 2020 Laboratory Services Excel
October 2024 OPPS Cover Sheet
October 2024 OPPS Fee Schedule PDF Rev. 11/27/2024
October 2024 OPPS Fee Schedule Excel Rev. 11/27/2024
July 2024 OPPS Cover Sheet
July 2024 OPPS Fee Schedule PDF
July 2024 OPPS Fee Schedule Excel
April 2024 OPPS Cover Sheet
April 2024 OPPS Fee Schedule PDF Rev. 05/03/2024
April 2024 OPPS Fee Schedule Excel Rev. 05/03/2024
January 2024 OPPS Coversheet
January 2024 OPPS Fee Schedule PDF
January 2024 OPPS Fee Schedule Excel
October 2023 OPPS Cover Sheet
October 2023 OPPS Fee Schedule PDF
October 2023 OPPS Fee Schedule Excel
July 2023 OPPS Cover Sheet
July 2023 OPPS Fee Schedule PDF
July 2023 OPPS Fee Schedule Excel
April 2023 OPPS Cover Sheet
April 2023 OPPS Fee Schedule PDF
April 2023 OPPS Fee Schedule Excel
January 2023 OPPS Cover Sheet
January 2023 OPPS Fee Schedule PDF
January 2023 OPPS Fee Schedule Excel
October 2022 OPPS Coversheet
October 2022 OPPS Fee Schedule PDF Rev. 11/18/2022
October 2022 OPPS Fee Schedule Excel Rev. 11/18/2022
July 2022 OPPS Coversheet
July 2022 OPPS Fee Schedule PDF Rev. 09/15/2022
July 2022 OPPS Fee Schedule Excel Rev. 09/15/2022
April 2022 OPPS Cover Sheet
April 2022 OPPS Fee Schedule PDF Rev. 08/30/2022
April 2022 OPPS Fee Schedule Excel Rev. 08/30/2022
January 2022 OPPS Cover Sheet
January 2022 OPPS Fee Schedule PDF Rev. 08/30/2022
January 2022 OPPS Fee Schedule Excel Rev. 08/30/2022
October 2021 OPPS Coversheet
October 2021 OPPS Fee Schedule PDF Rev. 08/30/2022
October 2021 OPPS Fee Schedule Excel Rev. 08/30/2022
July 2021 OPPS Coversheet
July 2021 OPPS Fee Schedule PDF Rev. 08/30/2022
July 2021 OPPS Fee Schedule Excel Rev. 08/30/2022
April 2021 OPPS Cover Sheet
April 2021 OPPS Fee Schedule PDF rev. 06/30/2021
April 2021 OPPS Fee Schedule Excel rev. 06/30/2021
January 2021 OPPS Cover Sheet
January 2021 OPPS Fee Schedule PDF
January 2021 OPPS Fee Schedule Excel
October 2020 OPPS Coversheet
October 2020 OPPS Fee Schedule PDF rev. 12/04/2020
October 2020 OPPS Fee Schedule Excel rev. 12/04/2020
July 2020 OPPS Coversheet
July 2020 OPPS Fee Schedule PDF rev. 11/05/2020
July 2020 OPPS Fee Schedule Excel rev. 11/05/2020
April 2020 OPPS Cover Sheet
April 2020 OPPS Fee Schedule PDF
April 2020 OPPS Fee Schedule Excel
January 2020 OPPS Cover Sheet
January 2020 OPPS Fee Schedule PDF rev. 08/31/2020
January 2020 OPPS Fee Schedule Excel rev. 08/31/2020
Instructions for Physician Administered Drug Prior Authorization:
- Please check posted criteria before submitting a prior authorization request. See below for list of drugs requiring prior authorization. Criteria can be found at Mountain-Pacific Quality Health – Medicaid Pharmacy (mpqhf.org). Make sure preferred drugs have been tried first and that there is documentation supporting this.
- Physician Administered Drug Prior Authorization requests must be submitted through the Qualitrac Portal at the following link: https://www.mpqhf.org/corporate/medicaid-portal-home/medicaid-portal-document-library/
- For questions, please contact Mountain-Pacific Quality Health Call Center:
(406) 443-0320 (Helena) or
(800) 219-7035 (Toll Free)
Reminders:
- Montana Medicaid does not reimburse for convenience, off label or experimental use of drugs, per Administrative Rules of Montana (ARM) 37.85.207.
- In general, drugs billed with unlisted codes require prior authorization from the State.
- NDC must be rebateable.
Drugs with specific criteria sets:Aduhelm (aducanumab-avwa)
Amondys 45 (casimersen)
Cinqair (reslizumab)
Entyvio (vedolizumab)
Evenity (romosozumab-aqqg)
Evkeeza (evinacumab-dgnb)
Exondys 51 (eteplirsen)
Fasenra (benralizumab)
Ilumya (tildrakizumab-asmn)
Krystexxa (pegloticase)
Lemtrada (alemtuzumab)
Leqvio (inclisiran)
Nucala (mepolizumab)
Prolia (denosumab)
Simponi Aria (golimumab infusion)
Skyrizi (risankizumab-rzaa)
Spinraza (nusinersen)
Spravato (esketamine)
Stelara (ustekinumab)
Sublocade (buprenorphine extended-release)
Supprelin LA (histrelin acetate)
Tezspire (tezepelumab)
Tremfya (guselkumab)
Viltepso (viltolarsen)
Vivitrol (naltrexone extended-release)
Vyepti (eptinezumab-jjmr)
Vyondys 53 (golodirsen)
Xgeva (denosumab)
Xolair (omalizumab)
Zinplava (bezlotoxumab)
Zolgensma (onasemnogene abeparvovec-xioi)
Zulresso (brexanolone)
2024
12/19/2024 IRS Tax Identification Letter Required for Pay-To Providers
12/06/2024 Coverage for Botox (onabotulinumtoxinA) REVISED
12/04/2024 Change in the Double Electric Breast Pump Provider
11/04/2024 Paper Claim Denials
10/30/2024 Beyfortus and Synagis Coverage for RSV Prophylaxis
10/18/2024 Electronic Adjustments Void or Void/Replace
10/15/2024 Revalidation Requirements Deadline
10/11/2024 COVID-19 Vaccine Codes Removed from Plan First Covered Codes List
09/18/2024 Vaccines for Children Code Update
08/09/2024 Vaccines for Children Code Update
07/29/2024 Prior Authorization Requirements When a Member Has Third Party Liability
06/28/2024 January 1, 2024 and July 1, 2024 Fee Schedule Updates
06/20/2024 Hospital Transfers: In State Versus Out of State
06/18/2024 DEA Number Required for Prescribers REVISED
06/11/2024 Health Resources Division Claims Appeal Process
05/21/2024 DEA Number Required for Prescribers
05/10/2024 Ordering Genetic Lab Tests from Assurex Health
05/08/2024 Vaccines for Children Code Update
05/01/2024 Paperwork Attachments Submission Timing for Electronic Claims
05/01/2024 Eligibility Inquiry and Service Type Code in the MATH Portal
04/30/2024 Diabetes Prevention Program Information
04/19/2024 Changes Regarding Opioid Prior Authorization and Medication for Opioid Use Disorder
04/08/2024 Negative Pressure Wound Therapy Pumps (E2402) Do Not Require Prior Authorization
04/05/2024 Written Orders for Physical, Occupational, and Speech Therapy
03/27/2024 HHS Letter to Healthcare Providers
03/27/2024 Resources for Providers in Response to the Change Healthcare Cyberattack
03/27/2024 Updated CLIA Claims Editing
03/27/2024 Avoiding Claim Denials
03/27/2024 Location Address and Provider Maintenance Updates
03/19/2024 Electronic Funds Transfer Payment Verification
03/12/2024 Valid Member ID and Eligibility Verification
03/12/2024 Provider Initiated Claims Adjustment
03/05/2024 Voiding Claims With a Prior Authorization
02/14/2024 How to Obtain a Double Electric Breast Pump, HCPCS E0603
02/14/2024 Medicaid 12-Month Postpartum Continuous Eligibility Coverage
02/08/2024 Hospital Facility Utilization Fee 2023
01/29/2024 Vaccines for Children Code Update
01/23/2024 Montana Healthcare Programs Support Services Holiday Closures REVISED
01/08/2024 AMP Cap Removal and Medication Access
01/08/2024 Electronic Claim Adjustment Processing Change
2023
12/22/2023 Passport Provider Referral Number on Claims
12/19/2023 Montana Prescription Drug Registry Survey
12/12/2023 Individual Providers Enrolled as Sole Proprietors Due for Revalidation
11/20/2023 Fetal Chromosomal Aneuploidy Testing REVISED
11/08/2023 Prior Authorization Information
11/01/2023 Beyfortus and Synagis Coverage for RSV Prophylaxis
10/31/2023 Managed Care Referrals IHS, Tribal 638, and Urban Indian Organizations REVISED
10/16/2023 Vaccines for Children Code Update
09/15/2023 Claims Payment Discrepancy Update
09/14/2023 Claims Payment Discrepancy Identified
09/08/2023 Medicaid Claims Payment Delayed
09/06/2023 Provider Rate Increases Systematic Adjustments
08/30/2023 Attestation Form Required for Qualifying Clinical Trials
08/01/2023 Provider License Expiration Reminder Letters
07/06/2023 Provider Rate Increases
05/26/2023 Medicaid Reimbursement and Court Ordered Services REVISED
05/08/2023 Diabetes Prevention Program (DPP) Information REVISED
05/05/2023 Medicaid Coverage of Abortion Services REVISED
05/03/2023 Makena PV Makena (Hydroxyprogesterone Caproate Injection) Coverage
05/01/2023 Medicaid Coverage of Abortion Services
04/10/2023 Resumption of Face-to-Face Requirements for Selected Programs REVISED
03/22/2023 Coverage and Reimbursement Policy for Telemedicine/Telehealth Services
03/22/2023 End of Public Health Emergency (PHE) Effects on Pharmacy Coverage
03/22/2023 Non-Covered Services Agreement Policy Return to Requirements
03/22/2023 Reinstatement of the Primary Care Provider Referral for Passport
03/22/2023 Resumption of Face-to-Face Requirements for Selected Programs
03/22/2023 Resumption of Prior Authorization Requirements Revised 04/03/2023
03/17/2023 End of Temporary Revision to Case Management General Provisions
03/10/2023 Provider Meetings for Medicaid Eligibility Redetermination and Unwinding PHE Flexibilities
03/09/2023 Add-on and E&M Code Editing
03/03/2023 End of Public Health Emergency
02/10/2023 837I Ancillary Charge Claim Rejections
01/04/2023 Montana Healthcare Programs Support Services Holiday Closures
2022
12/23/2022 Plan First Updated Code List Descriptions
11/09/2022 Prior Authorization Criteria for Synagis®
10/27/2022 Updated ICD-10 Obstetric Observation Diagnosis Codes REVISED
09/19/2022 Vaccines for Children (VFC) Code Update
09/19/2022 New Plan First Covered Code
09/01/2022 Sterilization Consent Form MA-38 to be Discontinued
08/05/2022 Bipartisan Budget Act of 2018 Cost Avoidance Statute Changes
06/17/2022 Plan First Updated Code List Descriptions
06/03/2022 Circumcision Prior Authorization Changes REISSUED
06/03/2022 New Early and Periodic Screening, Diagnostic and Treatment (EPSDT) Review and Process through Qualitrac Portal REISSUED
06/03/2022 Unlisted Billing Codes Reminder REISSUED
05/16/2022 Help Members Receive Important Information from Montana Medicaid and Stay Covered
05/13/2022 Revalidation Extended REVISED
05/13/2022 National Drug Code (NDC) Denial Errors
05/11/2022 Prior Authorization Qualitrac Portal REISSUED
05/09/2022 Physician Administered Drug Prior Authorization Information REVISED
04/26/2022 Health Behavior Assessment and Intervention Billing Codes REVISED
04/25/2022 Physician Administered Drug Prior Authorization Information Rev. 05/09/2022
03/29/2022 Nurse First Advice Line Services Ending
03/16/2022 Revalidation Extended to June 2022 REVISED Rev. 05/13/2022
02/23/2022 Revalidation Extended to June 2022 Rev. 03/16/2022
02/23/2022 Standing Orders and Medicaid Reimbursement
01/18/2022 Billing for Preventive Medicine Counseling
01/14/2022 Montana Healthcare Programs Support Services Holiday Closures
01/04/2022 Vaccines for Children (VFC) Code Update
2021
12/20/2021 Plan First Updated Code List Descriptions12/16/2021 Coverage for Botox (onabotulinumtoxinA)
12/15/2021 Health Behavior Assessment and Intervention Billing Codes REv. 04/26/2022
12/10/2021 New Provider Services Portal
09/28/2021 Laboratory Panel Billing
09/24/2021 Codes Removed from and Added to Plan First Covered Code List
09/23/2021 Prior Authorization Criteria for Synagis®
09/16/2021 Billing Update - Licensed Marriage and Family Therapist (LMFT)
09/16/2021 Off-Label Use of Ketamine
07/30/2021 Updated Criteria for ENTYVIO (vedolizumab)
07/20/2021 Fetal Chromosomal Aneuploidy Testing - Refer to 11/20/2023 Fetal Chromosomal Aneuploidy Testing REVISED
07/20/2021 Enrollment Update – Licensed Marriage and Family Therapist
07/13/2021 Prior Authorization Required for Lemtrada
07/06/2021 Adoption Of Temporary Emergency Rule To Allow for COVID-19-Related
Regulatory Discretion Beyond The Expiration Of The Governor-Declared State Of Emergency
07/06/2021 Procedure Code 58350, Chromotubation
06/11/2021 COVID-19 Vaccine Administration Billing Guidance
05/21/2021 Sterilization Consent Form MA-38 to be Discontinued
05/05/2021 Date Spans for Prior Authorization Through the Qualitrac Portal
04/02/2021 New Provider Type – Licensed Marriage and Family Therapist
03/04/2021 Reference Laboratory Billing Guidelines
01/28/2021 Montana Healthcare Programs Support Services Holiday Closures
01/27/2021 Vaccines for Children (VFC) Code Update
01/21/2021 Montana Plan First Additional Codes Added to Plan First Covered Code List
01/11/2021 Provider Support Services Closed for Martin Luther King Day, Monday, January 18, 2021
2020
12/07/2020 Medicaid Expansion Extended Through December 31, 2021
11/12/2020 Removal of Codes for COVID-19 Testing and Treatment
08/28/2020 Provider Relief Fund General Allocation REVISED
07/27/2020 Montana Plan First - Additional Covered Code, COVID - Testing
05/15/2020 Temporary Revision to Case Management General Provisions
04/30/2020 National Correct Coding Initiative Announcement
04/28/2020 Temporary Suspension of the PCP Referral Requirement
04/27/2020 Non-Covered Services Agreement Policy Change
04/22/2020 Suspension of Prior Authorizations or Continued Stay Reviews and Clinical Requirements for Some Medicaid Programs
04/01/2020 Suspension of Face to Face Requirements for Some Medicaid Programs
03/19/2020 Telemedicine Medicaid Coverage and Reimbursement Policy for Telemedicine/Telehealth rev 03/27/2020