Physician Physician Prior Authorization Forms Claim Jumper Newsletters Provider Manuals General Information for Providers Physician-Related Services 12/2017 This manual has information specific to your provider type. Prescription Drug Program 07/08/2019 This manual has information specific to your provider type. Passport to Health 10/2017 Everything a provider needs to know to become a successful Passport provider. Medicaid Rules and Regulations 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 Administrative Rules of Montana (Title 37) Chapter 79 Healthy Montana Kids Chapter 82 Medicaid Eligibility Chapter 83 Medicaid for Certain Medicare Beneficiaries and Others Chapter 85 General Medicaid Services Chapter 86 Medicaid Primary Care Services Fee Schedules – Physician January 2020 Physician Coversheet January 2020 Physician Fee Schedule PDF rev. 03/19/2020 January 2020 Physician Fee Schedule Excel rev. 03/19/2020 July 2019 Physician Coversheet July 2019 Physician Fee Schedule PDF July 2019 Physician Fee Schedule Excel January 2019 Physician Coversheet January 2019 Physician Fee Schedule PDF rev 04/11/2019 January 2019 Physician Fee Schedule Excel rev 04/11/2019 July 2018 Physician Coversheet Version 2 July 2018 Physician Fee Schedule Version 2 PDF July 2018 Physician Fee Schedule Version 2 Excel July 2018 Physician Coversheet July 2018 Physician Fee Schedule PDF July 2018 Physician Fee Schedule Excel January 2018 Physician Coversheet rev. 02/18/2018 Physician Fee Schedule January 2018 PDF rev. 06/05/2018 Physician Fee Schedule January 2018 Excel rev. 03/30/2018 Fee Schedules – ATP Tests and Fees July 2018 ATP Fee Schedule January 2018 ATP Fee Schedule January 2017 PDF: January 2017 ATP Excel: January 2017 ATP TXT: January 2017 ATP Provider Notices For prescription medication notices, see the Pharmacy page/ 2020 03/19/2020 Telemedicine Medicaid Coverage and Reimbursement Policy for Telemedicine/Telehealth rev 03/27/2020 03/19/2020 Telemedicine Policy Clarification Frequently Asked Questions on Telemedicine / Telehealth 03/12/2020 Medical Food or Formula for Phenylketonuria (PKU) due to Inborn Errors of Metabolism (IEM) - HCPCS Code S9435 02/28/2020 Starting Dose and Quantity Limitations for Sedative Hypnotics 02/25/2020 Physician Administered Drug Update 01/24/2020 Consent for Sterilization Form 01/03/2020 Changes to Hepatitis C Treatment Criteria 2019 12/27/2019 Elimination of Copayments 12/27/2019 Prior Authorization Criteria for Atypical Antipsychotics for Children 7 Years of Age and Under 12/04/2019 Dosage Restrictions for all Opioids based on Morphine Milligram Equivalents (MME) 11/22/2019 New Early and Periodic Screening, Diagnostic and Treatment (EPSDT) Review and Process through Qualitrac Portal 11/18/2019 HCPCS Modifiers - XE, XS, and XU (Reissued Notice) 11/15/2019 Chronic Care/Coordinated Care Codes Revised 11/14/2019 Prior Authorization Criteria for Synagis® 11/14/2019 Circumcision Prior Authorization Changes Re-Issued from 2016 11/14/2019 Daily Supply Kit by Day for Enteral Feeding (B4034, B4035, B4036) 09/11/2019 Medication-Assisted Treatment (MAT) Bundled Rates 08/27/2019 Electronic Prior Authorization Process for Suboxone Films for Medication Assisted Therapy rev. 08/27/2019 07/23/2019 Therapeutic Continuous Glucose Monitor and Sensors – K0554 & K0553 07/10/2019 Consent for Sterilization Form 07/09/2019 Vaccine Administration by Pharmacists 06/21/2019 Electronic Prior Authorization Process for Suboxone Films for Medication Assisted Therapy 05/20/2019 Nurse Visit - Appropriate Billing Reminder - Revised Clarification rev. 05/30/2019 05/10/2019 NDC Required on All Radiopharmaceuticals 05/01/2019 Dosage Restrictions for all Opioids based on Morphine Milligram Equivalents (MME) 04/01/2019 Durable Medical Equipment Criteria for Home Ventilators 03/25/2019 Montana Plan First - Change to Covered Procedures and Service Codes 03/20/2019 Prior Authorization Qualitrac Portal 03/07/2019 Systematic Approval Diagnosis for MRI of the Head and CT of the Brain (Revised) 02/15/2019 Systematic Approval Diagnosis for MRI of the Head and CT of the Brain 02/15/2019 Claims Processing for CT of the Brain and MRI of the Head 02/15/2019 DOT Medical Examination 01/31/2019 Kyleena®, Mirena®, and Skyla® Acquisition Costs 01/17/2019 Physician Administered Drug Update 01/15/2019 Sublocade® (Injectable Extended-Release Buprenorphine) 2018 11/30/218 Dosage Restrictions for all Opioids based on Morphine Milligram Equivalents (MME) 11/26/2018 Hearing Aid Services Adjustment for Rate Reduction 11/21/2018 Physician Administered Drug Prior Authorization Form 11/20/2018 Audiology Adjustment for Rate Restoration 11/20/2018 Appropriate Billing Reminder 1/13/2018 Diabetes Prevention Program (DPP) Claims Update 11/08/2018 Rate Updates Mass Adjustment 11/06/2018 Smart PA® Prior Authorization for Synagis® 11/06/2018 Vaccine Administration by Pharmacists 10/19/2018 Medicaid Fee Schedules 10/09/2018 CT of the Brain and MRI of the Head Tips 10/03/2018 Vaccine for Children Code Update - Revised 10/02/2018 MRI Brain with Contrast Radiology - revised 10/02/2018 CT of the Brain Radiology - revised 09/24/2018 Prior Authorization for Genetics Testing for Youth Mental Health 09/18/2018 MRI of the Brain with Contrast Radiology - revised 09/18/2018 CT of the Brain Radiology - revised 07/24/2018 Diabetes Prevention Program (DPP) Coding Change 07/18/2018 Drugs Not Covered For MAT Members 07/17/2018 Caregiver Depression Screenings Reissued Notice 07/16/2018 Elective Deliveries Re-Issued Notice 07/05/2018 Dosage Restrictions For All Opioids Based On Morphine Milligram Equivalents (MME) - this has been replaced with the provider notice dated 11/30/2018. 07/02/2018 Updated CLIA Claims Editing 06/12/2018 Approved Diagnosis Codes for Botox 06/04/2018 Coding Resources Change 05/30/2018 Panniculectomy Criteria 04/25/2018 Changes to the Medicare Part D Drug Benefit for Dual Eligible Members – Benzodiazepines 04/04/2018 Updated Passport Eligible Populations & Reimbursement 03/22/2018 Criteria for Breast Reconstruction 03/15/2018 Criteria for MRI of the Brain rev. 04/10/2018 03/15/2018 Criteria for CT of the Brain rev. 04/10/2018 03/14/2018 Prior Authorization for Genetics Testing for Youth Mental Health 03/02/2018 Physician Administered Drug Update rev. 03/08/2018 03/02/2018 Physician Administered Drug Update 02/27/2018 DME Incontinence Supply Rates 02/26/2018 New Rendering Only Provider Enrollment Application 02/20/2018 Advanced Imaging Prior Authorization 02/12/2018 Makena Injection Code Change and Reimbursement 01/31/2018 Montana Healthcare Programs Covered Double Electric Breast Pumps - E0603 01/30/2018 Fetal Chromosomal Aneuploidy Testing 01/30/2018 Psych Care Management New Codes 99492 - 99494 01/17/2018 Xgeva® Prior Authorization Criteria 01/12/2018 Zinplava Prior Authorization Criteria (Revised, provider types added) Other Resources Prior Authorization Criteria for Specific Services Rebateable Manufacturers 10/02/2019 SURS Provider Self-Audit Protocol 10/2015 To locate older documents, access the Archive Page.