Mid-Level Practitioner

Prior Authorization Forms Claim Jumper Newsletters

General Information for Providers  
Medicaid manual with general information for all provider types.

Prescription Drug Program
This manual has information specific to your provider type.

Physician-Related Services
This manual has information specific to your provider type.

Passport to Health
Everything a provider needs to know to become a successful Passport provider.

Prior Authorization Criteria for Specific Services

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
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 (DDP) 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
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

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
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 - Refer to 11/20/2032 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
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)
05/05/2021 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

2020

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
1/12/2020 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
10/08/2020 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
04/24/2020 Changes to Youth Community-Based Psychiatric Rehabilitation and Support Services
04/23/2020 Elimination of Prior Authorization and Criteria Requirements for MRI of the Head and CT of the Brain

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
03/26/2020 Montana Plan First - Additional Covered Codes, Telemedicine/Telehealth
03/19/2020 Telemedicine Medicaid Coverage and Reimbursement Policy for Telemedicine/Telehealth  rev 03/27/2020

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
01/10/2020 Co-Payment Assessed in Error for January 6, 2020
01/03/2020 Changes to Hepatitis C Treatment Criteria