Hospital Outpatient

Prior Authorization Forms Claim Jumper Newsletters

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

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

 

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:

  1. 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.
  2. 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/ 
  3. 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 

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 Descriptions
12/16/2021 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