General Information for Providers
Medicaid manual with general information for all provider types.
Physician-Related Services
This manual has information specific to your provider type.
Prescription Drug Program
This manual has information specific to your provider type.
Passport to Health
Everything a provider needs to know to become a successful Passport provider.
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
January 2023 Physician Coversheet
January 2023 Physician Fee Schedule PDF Rev. 03/01/2023
January 2023 Physician Fee Schedule Excel Rev. 03/01/2023
July 2022 Physician Coversheet
July 2022 Physician Fee Schedule PDF Rev. 09/12/2022
July 2022 Physician Fee Schedule Excel Rev. 09/12/2022
January 2022 Physician Coversheet
January 2022 Physician Fee Schedule PDF Rev 04/27/2022
January 2022 Physician Fee Schedule Excel Rev. 04/27/2022
July 2021 Physician Coversheet
July 2021 Physician Fee Schedule PDF Rev. 11/10/2021
July 2021 Physician Fee Schedule Excel Rev. 11/10/2021
January 2021 Physician Coversheet
January 2021 Physician Fee Schedule PDF Rev. 02/18/2021
January 2021 Physician Fee Schedule Excel Rev. 02/18/2021
July 2020 Physician Coversheet
July 2020 Physician Fee Schedule PDF rev. 08/31/2020
July 2020 Physician Fee Schedule Excel rev. 08/31/2020
January 2020 Physician Coversheet
January 2020 Physician Fee Schedule PDF rev. 06/03/2020
January 2020 Physician Fee Schedule Excel rev. 06/03/2020
Prior Authorization Criteria for Specific Services
Instructions for Physician Administered Drug Prior Authorization:
Reminders:
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)
For prescription medication notices, see the Pharmacy page
06/01/2023 Billing Guidance for Tracheostomy Tubes for Members Aged 20 and Under
05/26/2023 Medicaid Reimbursement and Court Ordered Services REVISED
05/08/2023 Diabetes Prevention Program (DPP) Information REVISED05/05/2023 Medicaid Coverage of Abortion Services REVISED
05/03/2023 Makena PV Makena (Hydroxyprogesterone Caproate Injection) Coverage
05/01/2023 Non-Adjunctive (Therapeutic) and Adjunctive (Non-Therapeutic) Continuous Glucose Monitors (CGMs) Policy Revision
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
01/31/2023 Omnipod Coverage
01/04/2023 Montana Healthcare Programs Support Services Holiday Closures
12/23/2022 Plan First Updated Code List Descriptions
11/09/2022 Prior Authorization Criteria for Synagis®
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
02/28/2022 COVID-19 At-Home Test Coverage
02/23/2022 Revalidation Extended to June 2022 Rev. 03/16/2022
02/23/2022 Standing Orders and Medicaid Reimbursement
02/08/2022 Vaccine Administration by Pharmacists
02/02/2022 Dose Limitations for Gabapentinoids
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
01/03/2022 Non-Therapeutic CGM Devices
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
11/02/2021 Therapeutic Continuous Glucose Monitor (CGM) Devices
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
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
07/01/2021 Global Surgical Package
06/11/2021 COVID-19 Vaccine Administration Billing Guidance
06/11/2021 Procedure Code 58350, Chromotubation
05/21/2021 Sterilization Consent Form MA-38 to be Discontinued
05/18/2021 Medication Assisted Treatment (MAT) Services Are Only Approved to Treat Members with an Opioid Use Disorder (OUD)
05/12/2021 Removal of DLA-20 Requirement from Transcranial Magnetic Stimulation (TMS) Services
05/05/2021 Date Spans for Prior Authorization Through the Qualitrac Portal
04/08/2021 Electronic Prior Authorization Process for Suboxone® Films for Medication Assisted Therapy
04/02/2021 New Provider Type – Licensed Marriage and Family Therapist
03/04/2021 Reference Laboratory Billing Guidelines
03/01/2020 DME and DME EPSDT Prior Authorizations Through the Qualitrac Portal
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
12/23/2020 Diabetes Prevention Program (DPP) Information
12/07/2020 Medicaid Expansion Extended Through December 31, 2021
12/01/2020 Change in Application Process for Plan First
11/25/2020 Physician Administered Drug (PAD) Prior Authorization Requests Revised
11/17/2020 Prior Authorizations Through the Qualitrac Web Portal for DME and DME EPSDT
11/12/2020 Removal of Codes for COVID-19 Testing and Treatment
11/10/2020 Prior Authorization Criteria for Synagis®
10/28/2020 Provider Relief Fund General Allocation
10/19/2020 Discarded Drugs and Biologicals and the Use of the JW Modifier
10/08/2020 Montana Plan First - Addition of Radiologic Examination Codes for Abdomen; 1, 2, and 3 Views
10/02/2020 Reimbursement for CPT Code 90694 FLUAD Quadrivalent
10/02/2020 Select P Codes Allowable in a Physician Setting for Hospital Owned Physician Clinics
10/02/2020 SINUVA® and PROPEL® (mometasone furoate) Sinus Implants
08/28/2020 Provider Relief Fund General Allocation rev. 08/28/2020
08/11/2020 Provider Relief Fund General Allocation rev. 08/11/2020
08/10/2020 Physician Administered Drug (PAD) Prior Authorization Requests - Revised
07/27/2020 Montana Plan First - Additional Covered Code, COVID - Testing
07/24/2020 Provider Relief Fund General Allocation
07/20/2020 Outpatient Psychotherapy Limits
07/17/2020 Medicaid Reimbursement and Court Ordered Services
06/26/2020 Vaccine Administration by Pharmacists
06/18/2020 P Codes Not Allowable in a Physician Setting and Not Eligible for Reimbursement
06/17/2020 National Correct Coding Initiative Announcement
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
04/23/2020 Elimination of Prior Authorization and Criteria Requirements for MRI of the Head and CT of the Brain
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
03/19/2020 Telemedicine Policy Clarification
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