Psychiatrist

Prior Authorization Forms Claim Jumper Newsletters

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.

Mental Health Services – Adult
This manual has information specific to your provider type.
This link brings you to the AMDD page of the DPHHS.mt.gov website.

Mental Health Services – Children 
This link brings you to Manuals and Guides on the Department website.

Prescription Drug Program, Prior Authorization Chapter
This manual has information specific to your provider type.

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

11/04/2024 Paper Claim Denials
10/18/2024 Electronic Adjustments Void or Void/Replace
10/15/2024 Revalidation Requirements Deadline
06/28/2024 January 1, 2024 and July 1, 2024 Fee Schedule Updates
06/18/2024 DEA Number Required for Prescribers REVISED
05/21/2024 DEA Number Required for Prescribers
05/01/2024 Paperwork Attachments Submission Timing for Electronic Claims
05/01/2024 Eligibility Inquiry and Service Type Code in the MATH Portal04/19/2024 Changes Regarding Opioid Prior Authorization and Medication for Opioid Use Disorder
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
01/23/2024 Montana Healthcare Programs Support Services Holiday Closure REVISED
01/08/2024 Electronic Claim Adjustment Processing Change 

2023

12/22/2023 Passport Provider Referral Number on Claims
12/12/2023 Individual Providers Enrolled as Sole Proprietors Due for Revalidation
11/08/2023 Prior Authorization Information
10/31/2023 Managed Care Referrals IHS, Tribal 638, and Urban Indian Organizations 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
08/01/2023 Provider License Expiration Reminder Letters
07/06/2023 Provider Rate Increases
05/26/2023 Medicaid Reimbursement and Court Ordered Services REVISED
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
01/04/2023 Montana Healthcare Programs Support Services Holiday Closures

2022

08/05/2022 Bipartisan Budget Act of 2018 Cost Avoidance Statute Changes
07/05/2022 Resumption of Prior Authorizations and Continued Stay Reviews Updated
05/27/2022 Resumption of Prior Authorizations and Continued Stay Reviews
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
05/09/2022 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
01/14/2022 Montana Healthcare Programs Support Services Holiday Closures

2021

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
09/16/2021 Billing Update - Licensed Marriage and Family Therapist (LMFT)
09/16/2021 Off-Label Use of Ketamine
07/20/2021 Enrollment Update – Licensed Marriage and Family Therapist
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
06/11/2021 COVID-19 Vaccine Administration Billing Guidance
05/12/2021 Removal of DLA-20 Requirement from Transcranial Magnetic Stimulation (TMS) Services
04/02/2021 New Provider Type – Licensed Marriage and Family Therapist
01/28/2021 Montana Healthcare Programs Support Services Holiday Closures
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  
10/28/2020 Provider Relief Fund General Allocation
08/28/2020 Provider Relief Fund General Allocation rev. 08/28/2020

08/20/2020 Behavioral Health Grants
08/11/2020 Provider Relief Fund General Allocation rev. 08/11/2020

07/24/2020 Provider Relief Fund General Allocation

07/17/2020 Medicaid Reimbursement and Court Ordered Services
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

04/22/2020 Suspension of Prior Authorizations or Continued Stay Reviews and Clinical Requirements for Some Medicaid Programs

s
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

01/10/2020 Co-Payment Assessed in Error for January 6, 2020

To locate older documents, access the Archive Page.