Physician
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 2025 Physician Coversheet
January 2025 Physician Fee Schedule PDF Rev. 03/14/2025
January 2025 Physician Fee Schedule Excel Rev. 03/14/2025
July 2024 Physician Coversheet
July 2024 Physician Fee Schedule PDF Rev. 12/12/2024
July 2024 Physician Fee Schedule Excel Rev. 12/12/2024
January 2024 Physician Coversheet
January 2024 Physician Fee Schedule PDF
January 2024 Physician Fee Schedule Excel
July 2023 Physician Coversheet
July 2023 Physician Fee Schedule PDF Rev. 03/14/2024
July 2023 Physician Fee Schedule Excel Rev. 03/14/2024
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:
- Please check posted criteria for the drugs listed below before submitting a prior authorization request. Criteria can be found at Pharmacy Services - Mountain Pacific by scrolling to PA Forms and Drug Criteria Documents. 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 Mountain Pacific Provider Portal
- For questions, please contact Mountain Pacific 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:
Brixadi (buprenorphine extended-release)
Cinqair (reslizumab)
Entyvio (vedolizumab)
Evenity (romosozumab-aqqg)
Evkeeza (evinacumab-dgnb)
Fasenra (benralizumab)
Ilumya (tildrakizumab-asmn)
Kisunla (donanemab-azbt)
Krystexxa (pegloticase)
Lemtrada (alemtuzumab)
Leqembi (lecanemab-irmb)
Leqvio (inclisiran)
Nucala (mepolizumab)
Omvoh (mirikizumab-mrkz)
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)
Tzield (teplizumab-mzwv)
Vivitrol (naltrexone extended-release)
Vyepti (eptinezumab-jjmr)
Xgeva (denosumab)
Xolair (omalizumab)
Zolgensma (onasemnogene abeparvovec-xioi)
For prescription medication notices, see the Pharmacy page
2025
04/29/2025 Audio - Only Codes
04/23/2025 Written Orders Regarding Occupational, Physical, and Speech Therapy
04/23/2025 DME Claims Processing Instructions for Enteral and Parenteral Nutrition
03/31/2025 Payment To Be Suspended for Providers Without Current Financial Information
03/06/2025 Monthly Supply Allowance for Continuous Glucose Monitors - A4238 or A4239
02/11/2025 EFT Authorization Agreement Updated
02/04/2025 Health Behavior Assessment and Intervention Billing Codes
01/21/2025 Transcranial Magnetic Stimulation Services, Provider Requirements, and Medical Necessity Criteria
01/15/2025 Total Electric Hospital Bed Coverage Criteria
01/15/2025 Montana Healthcare Programs Support Services Holiday Closures
01/06/2025 Montana Prescription Drug Registry Survey for Federal Fiscal Year 2024
2024
12/19/2024 Free Virtual Training Opportunity!
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
06/18/2024 Method for Submitting Durable Medical Equipment Prior Authorizations
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
01/29/2024 Vaccines for Children Code Update
01/23/2024 Montana Healthcare Programs Support Services Holiday Closure REVISED
01/17/2024 Prior Authorization Criteria for Atypical Antipsychotics for Children 8 Years of Age and Under 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
09/28/2023 Medical Food or Formula for Phenylketonuria (PKU) Due to Inborn Errors of Metabolism (IEM) REVISED
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
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 REVISED
05/05/2023 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
2022
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