Printing the manual material found at this website for long-term use is not advisable. Department Policy material is updated periodically and it is the responsibility of the users to check and make sure that the policy they are researching or applying has the correct effective date for their circumstances.
This edition has three search options.
Prior manuals may be located through the provider website archives.
Updated 06/01/2023
To print this manual, right click your mouse and choose "print". Printing the manual material found at this website for long-term use is not advisable. Department of Public Health and Human Services (DPHHS) Policy material is updated periodically, and it is the responsibility of the users to check and make sure that the policy they are researching or applying has the correct effective date for their circumstances.
This publication supersedes all previous Passport to Health (Passport) guides and manuals. First published by the Department of Public Health and Human Services (DPHHS), December 2003.
Updated September 2004, September 2005, March 2008, May 2009, September 2013, August 2015, November 2015, September 2017, January 2019, January 2020, March 2022, March 2023, and June 2023.
CPT codes, descriptions, and other data are under copyright and are from the American Medical Association’s most current CPT manual published. All Rights Reserved. Applicable FARS/DFARS apply.
06/01/2023
04/14/2023
Updated entire manual.
04/01/2022
01/01/2020
01/18/2019
Updated whole manual with current terms, programs, policies, and links.
09/29/2017
Passport to Health Manual converted to an HTML format and adapted to 508 Accessibility Standards.
11/09/2015
Passport to Health, November 2015: Passport Referrals
Contact hours are 8 a.m. to 5 p.m. Monday–Friday Mountain Time unless otherwise stated.
The numbers designated TDD and TYY have a telecommunication device for people who need assistance hearing. Persons with disabilities who need an alternative accessible format of this information, or who require some other reasonable accommodation to participate in Montana Medicaid/HMK Plus, should contact DPHHS through the Passport to Health program.
IHS/Tribal Program Officer
Health Resources Division (HRD)
DPHHS
P.O. Box 202951
Helena, MT 59620-2951
(406) 444-4540
(406) 444-1861 Fax
To request a fair hearing or administrative review, email hhsofh@mt.gov or mail the request to the address below:
Office of Fair Hearings
DPHHS
P.O. Box 202953
Helena MT 59620-2953
(406) 444-2470
For forms and information on providing interpretive services to members, call the Montana Medicaid/HMK Plus at (406) 444-4540.
Telecommunications assistance for the hearing impaired.
Montana Relay Services Email: relay@mt.gov
(800) 833-8503 Voice, TTY
(406) 444-1335 Voice, TTY
For complaints about alleged discrimination because of race, color, national origin, age or disability, or other protected classes. Hours are 8 a.m. to 4 p.m. Mountain Time.
(406) 444-0262
Member Complaint Coordinator
Office of Human Resources
DPHHS
P.O. Box 4210
Helena, MT 59620-4210
(800) 368-1019
(800) 537-7697 TDD
Members who have Medicaid/HMK Plus questions, are looking for a provider, or want to choose a Passport provider may call the Montana Healthcare Programs Member Help Line:
(800) 362-8312
Providers with questions regarding Passport may contact the Conduent Passport Provider Analyst or the Passport Program Officer.
Conduent Passport Provider Analyst
(406) 457-9542
(406) 442-2328 Fax
Passport to Health Program
P.O. Box 254
Helena MT 59624-0254
Passport Program Officer
Providers who have policy or program questions and concerns or need to report errors, omission, or discrepancies in member utilization and cost reports may contact the Passport program officer.
(406) 444-4540
(406) 444-1861 Fax
Passport Program Officer
Member Health Management Bureau
P.O. Box 202951
Helena MT 59620-2951
For questions regarding the Team Care Program:
(406) 444-4540
(406) 444-1861 Fax
Team Care Program Officer
Member Health Management Bureau
P.O. Box 202951
Helena MT 59620-2951
Passport to Health (Passport) is the primary care case management (PCCM) program for the following Montana Healthcare Programs: Standard Medicaid, HELP Program/Medicaid Expansion, and Healthy Montana Kids Plus. The Passport to Health program provides case management related services that include locating, coordinating, and monitoring primary healthcare services. To achieve this, the Passport program works with the state’s other care coordination programs:
Montana Medicaid and HMK Plus members who are eligible for Passport must enroll in the program. See the Member Enrollment and Eligibility Chapter of this manual for a list of members who are ineligible for Passport. Each member has a designated Passport provider such as a physician, mid-level practitioner, or primary care clinic.
The Passport provider delivers PCCM services to their members. This means they provide or coordinate the member’s care and make referrals to other Montana Healthcare Programs providers when necessary. The member’s Passport provider is also referred to as the primary care provider (PCP).
Most services provided to Passport members must be provided by or referred by the member’s Passport provider. Other Medicaid providers will not be reimbursed for their services without a Passport provider's referral.
The Agency for Healthcare Research and Quality (AHRQ) defines care coordination as “deliberately organizing [member] care activities and sharing information among all of the participants concerned with a [member's] care to achieve safer and more effective care. This means that the [member’s] needs and preferences are known ahead of time and communicated at the right time to the right people, and that this information is used to provide safe, appropriate, and effective care to the [member].”
The PCCM model facilitates a strong member–provider relationship by providing primary, preventive, and routine services; managing and coordinating the member’s services; and acting as the front door to Montana Medicaid/HMK Plus services. To be an effective PCP, a provider’s office or facility must be:
Providers must be familiar with all current rules and regulations governing the Montana Medicaid/HMK Plus program. Provider manuals assist providers in billing Montana Medicaid/ HMK Plus; they do not contain all Montana Medicaid rules and regulations. Rule citations in the text are a reference tool; they are not a summary of the entire rule. Administrative Rules of Montana may be found at Administrative Rules of the State of Montana (mt.gov).
Paper copies of rules are available through the Secretary of State’s office. In addition to the general Montana Medicaid rules outlined in the General Information for Providers Manual and the rules outlined in each program manual, the following rules and regulations are also applicable to the Passport to Health program:
The Member Health Management Bureau (MHMB), a part of the Health Resources Division (HRD) of DPHHS, administers the Passport program and its ancillary programs: Team Care, PCMH, and CPC+. The MHMB determines services and policy regarding these programs. Manuals and other information are available on the Provider Information website.
The Montana Healthcare Programs Member Help Line assists members with Passport provider enrollment, helps them locate or change providers, and answers their Montana Medicaid/ HMK Plus and Passport questions. Additionally, the Montana Healthcare Programs Member Help Line assists pharmacies and Team Care members with pharmacy unlocks.
Provider Relations answers provider questions about Montana Healthcare Programs services, claims, and eligibility, and addresses provider concerns.
Providers may also call the Conduent Passport Provider Analyst to discuss problems or questions regarding Passport members or to enroll in Passport. See the Key Contacts and Websites chapter in this manual.
Providers should keep up with changes and updates to the Passport program by reading the Claim Jumper, Montana Healthcare Program’s monthly online newsletter, and any Passport provider notices issued.
A PCP can be a physician or a mid-level practitioner who provides PCCM services by agreement with DPHHS. DPHHS allows any provider who has primary care within their professional scope of practice to be a PCP. However, DPHHS does recognize that certain specialties are more likely to practice primary care, and actively recruits these providers.
To enroll in Passport, Montana Medicaid/HMK Plus providers must meet the following requirements. (ARM 37.86.5111)
The Passport provider agreement and this manual are available on the Passport page of the Provider Information website. Providers may also call the Conduent Passport Provider Analyst for information on becoming a Passport provider and to get the Passport provider agreement.
Solo Passport Provider
A solo Passport provider is enrolled in the program as an individual provider with one Passport number. The solo provider is listed as the member’s Passport provider. The solo provider is responsible for managing his or her individual Passport caseload. For details on referral documentation, see the Passport Referral chapter in this manual. Case management fees are paid to the individual provider under the solo provider’s Passport number in addition to the fee-for-service reimbursement.
Group Passport Provider
A group Passport provider is enrolled in the program as having one or more Montana Medicaid/HMK Plus providers practicing with one Passport number. The group name will be listed as the member’s Passport provider and could be a private group clinic, Rural Health Clinic, Federally Qualified Health Center, or Indian Health Service (IHS) clinic. All participating providers sign the Passport agreement group signature page and are responsible for managing the caseload. With a group provider, members may visit any provider within the group practice without a Passport referral. Case management fees are paid to a group under the group Passport number in addition to the fee-for-service reimbursement.
Passport providers must provide or arrange for suitable coverage for needed services, consultation, and approval or denial of referrals during posted normal business hours. If another provider is covering, the covering provider need not be enrolled as a Passport provider, but must be a Montana Medicaid/HMK Plus provider. Coverage can be provided by a physician, physician's assistant, or advanced practice registered nurse. The covering provider must have permission from the member's Passport provider number for claims.
Posted Normal Office Hours Coverage
May consist of a receptionist or equivalent, telephone system that will get the member to medical staff, or any appropriate method that provides the member access to the PCP or someone who can make medical decisions.
24-Hour Coverage
Passport providers must provide direction to members in need of emergency care 24/7/365. Acceptable direction includes an answering service, call forwarding, provider on-call coverage, or answering machine message. When a message is used, it should state at a minimum: If this is a medical emergency, hang up and either call 911 or go to the emergency department. Passport providers are required to provide education to their members regarding the appropriate use of the emergency department.
Vacation, Illness, and Other Absences
During periods of absence, providers must arrange for coverage for posted normal office hours as specified above. Passport members must have access to services or referrals from the covering provider(s).
Inability to Perform Services
Solo Passport providers are required to let DPHHS know if they are unable to fulfill their Passport to Health duties. If they cease to fulfill their Passport agreement and fail to arrange for other coverage, the member's will be disenrolled to the beginning of the month in which the provider was unable to make appropriate arrangements.
If the provider’s office provides documentation that coverage arrangements were made in advance, their members will not be disenrolled for a reasonable time. In such instances, DPHHS will work closely with the provider's office to determine if the condition will be long term and will require disenrollment.
Members will not be disenrolled from a group Passport provider if one provider becomes unable to provide or refer members for services as the remaining providers in the group shall provide the required PCCM coverage.
Passport providers may not distribute any marketing materials without first obtaining approval from DPHHS. Any marketing plans must also be submitted to DPHHS for prior written approval. Providers may not conduct direct or indirect marketing activities that are intended to influence members to enroll with the PCP or disenroll from another PCP.
There are no caseload limits, but there are minimums:
Passport providers who reach their caseload capacity have the opportunity to increase capacity by a minimum of 10% or more in order to have more Passport members choose or be assigned to them.
Providers must notify Provider Relations in writing within 30 days of changes that include the following:
When a provider wishes to terminate their Passport to Health enrollment, DPHHS requires a written notification at least 30 days in advance of the desired termination or removal date. Written notification is sent to Provider Relations. It is important to also give members at least 30 days' notice before termination to allow them enough time to choose another Passport provider. To ensure continuity of care during these 30 days, the provider must continue to treat the members or refer them to another provider.
Passport providers are subject to utilization review to verify the care and services provided through the program are fulfilling the requirements of the Passport provider agreement. (ARM 37.86.5111)
Team Care is a companion program of Passport to Health designed to educate members how to appropriately and effectively access medical care. Members enrolled in Team Care are also enrolled in Passport. Enrollment in Team Care is based on utilization that is found to be excessive, inappropriate, or fraudulent with respect to need. Montana Medicaid/HMK Plus members can be referred to Team Care by Drug Utilization Review Clinical Case Managers, PCPs, pharmacists, hospitals, or from claims data mining.
Team Care follows the same Passport rules and guidelines for referrals, enrollment/disenrollment, prior authorization, and billing processes. However, members enrolled in Team Care are restricted to one pharmacy.
When checking Montana Medicaid/HMK Plus eligibility, a Team Care member's provider and pharmacy will be listed. Providers must write all Montana Medicaid/HMK Plus prescriptions to the designated pharmacy. (ARM 37.86.5303)
Providers are encouraged to make a referral to the Team Care Program Officer if they feel one of their members is appropriate for the program. A Passport provider receives a case management fee of $6 per member per month (PMPM) for Team Care members. Passport providers are enrolled in either PCMH or CPC+ will receive a tiered PMPM payment for their attributed Team Care members based on the member's risk as described in the sections below.
Patient Centered Medical Home (PCMH) is a companion program of Passport to Health designed to support providers who have reached National Committee for Quality Assurance (NCQA) PCMH certification.
PCMH is a medical home model of care that offers a way to improve healthcare by transforming how primary care is standardized and delivered. The PCMH model of care is based on the following core principles:
Providers contract with DPHHS to provide PCMH care management services and receive increased PMPM care management fees based on the member’s risk score. Members are assigned a health risk score based on their score of potential risk across the entire population and are divided into three tiers. The care management fee amount corresponds to the risk-tier level.
Tier PMPM rates
PCMH providers have the option to participate in Tier 4, Complex Care Management (CCM). The purpose of CCM tier is to partner with PCMH providers to reduce costly services for Medicaid members with high utilization of emergency department visits and hospital admissions that might have been prevented by less costly interventions and primary care. The CCM program is aimed at working with Medicaid members in their homes to improve the health of members with high utilization by focusing on both medical and non-medical factors that may be impacting the member’s health.
Providers are reimbursed $470.10 per member per month for members actively enrolled in PCMH Tier 4 CCM.
PCMH providers enrolled in Tier 4 CCM must meet the following criteria:
Members must meet specific requirements to be enrolled in Tier 4 CCM including:
PCMH providers report quality measures annually to DPHHS. Medicaid merges claims data with the providers’ clinical data for each measure to determine performance rates for each measure. The quality measures include preventive services and utilization elements.
The PCMH program follows the same Passport rules and guidelines for referrals, enrollment/disenrollment, prior authorization, and billing processes. Practices must maintain PCMH recognition by the NCQA.
Providers wishing to enroll in the PCMH program should contact the Passport Program Officer to request additional details.
Comprehensive Primary Care Plus (CPC+) is a companion program of Passport to Health. CPC+ is an initiative developed by CMS with the goal to transition fee-for-service to value-based payments in collaboration with commercial payers in selected regions.
CPC+ payer partners and providers are collaborating around the goals of smarter healthcare spending, more effective healthcare delivery, and healthier patients.
For the purposes of the CPC+ Initiative, Montana Medicaid will only contract with primary care practices other than Federally Qualified Health Centers and Rural Health Clinics that meet at least one of the following criteria:
The program includes Track 1 and Track 2 practices; Track 2 practices have additional care delivery requirements including:
Providers contract with DPHHS to provide CPC+ care management services and are reimbursed risk-stratified, PMPM care management fees. Members are assigned a health risk score based on their score of potential risk across the entire population and are divided into tiers based on the provider track.
| Track 1 | PMPM Fee | Track 2 | PMPM Fee |
|---|---|---|---|
| Tier 1 | $3.33 | Tier 1 | $6.33 |
| Tier 2 | $9.33 | Tier 2 | $12.33 |
| Tier 3 | $15.33 | Tier 3 | $18.33 |
| Tier 4 | $21.33 | Tier 4 | $24.33 |
| Tier 5 | $34.33 |
CPC+ providers report quality measures annually to DPHHS. DPHHS merges claims data with the providers’ clinical data for each measure to determine performance rates for each measure. The quality measures include preventive services and utilization elements. Providers are eligible for annual quality incentive payments for meeting quality measure benchmarks.
CPC+ program follows the same Passport rules and guidelines for referrals, enrollment/ disenrollment, prior authorization, and billing processes.
Providers wishing to enroll in the CPC+ program should contact the Passport Program Officer to request additional details.
The Tribal Health Improvement Program (T-HIP) is a historic partnership between the Tribal, State and Federal governments to address factors that contribute to health disparities in the American Indian population eligible for Montana Medicaid/HMK Plus and residing on a reservation.
T-HIP services are designed to help members:
T-HIP is a three-tier program administered by a federally recognized tribe. A tribe may choose which level they wish to participate at. Implementation of Tier 1 is mandatory prior to participating in Tier 2 and Tier 3. Tier 1 focuses on high-risk, high-cost members identified by DPHHS. Services provided under Tier 1 seek to improve the health of members who have chronic illnesses or are at risk of developing serious health conditions through intensive care coordination of individual members. The services in Tier 1 also seek to enhance the communication and coordination link between the member and the Passport PCP. In addition to Tier 1 there are two other Tier choices. Tier 2 and Tier 3 address specific health focus areas that contribute to health disparities.
Passport referral and prior authorization are different. Passport referral is a referral to visit another provider; prior authorization refers to a list of services that require DPHHS authorization before they are performed. Some services may require a Passport referral and/or prior authorization. Passport referral is obtained by contacting the member's Passport provider. Prior authorization is obtained through a DPHHS contractor, Mountain-Pacific Quality Health (MPQH).
In addition, Passport referral reinforces a member's medical home relationship, but does not take the place of required written chart order for therapy services. See ARM 37.86.606(3)(a).
Different numbers are issued for Passport referral and prior authorization, and if required, both numbers must be listed on the requesting provider's claim. For more information on prior authorization, see the Prior Authorization chapter in the General Information for Providers Manual, your provider type manual, and the Prior Authorization page on the Provider Information website.
Copayments are not assessed for Medicaid or Healthy Montana Kids Plus members.
Service limits are the same for Passport members and non-Passport members. For more information on service limits, see the Montana Healthcare Programs billing manual for your provider type and the General Information for Providers Manual, both available on the Provider Information website.
A monthly Passport enrollee list is sent to each Passport provider by the first day of each month to assist Passport providers in managing their Passport members. Below is a sample enrollee list.
Providers should contact new members to set up an appointment to establish care and introduce new members to their practice, office policies, and staff. If a member has been on a provider’s list before but is shown as a new member, he/she may have lost Montana Medicaid/HMK Plus eligibility for a period of time.
| Passport Enrolled Client List | |||||
|---|---|---|---|---|---|
| Client Name | Medicaid ID |
Birth Date | Address | Phone | New Enrollee |
| GUNDER, HANS | XXXXXXXXX | 5/30/1980 | PO BOX 1584 HELENA, MT 59601 | 406-XXX-XXXX | No |
| IMSEN, RAGA | XXXXXXXXX | 2/7/1969 | 822 HENRY ST, HELENA, MT 59601 | 406-XXX-XXXX | Yes |
| LANTZ, SUNNY | XXXXXXXXX | 11/11/2000 | 677 1ST ST, HELENA, MT 59601 | 406-XXX-XXXX | No |
| OSTER, FELIX | XXXXXXXXX | 12/4/1989 | 11 SADDLE RD, HELENA, MT 59601 | 406-XXX-XXXX | No |
| POLLY, PENNY | XXXXXXXXX | 9/15/1976 | 27 MAIN ST, HELENA, MT 59601 | 406-XXX-XXXX | No |
| TURNER, SAM | XXXXXXXXX | 4/29/1955 | 646 STURN LN, HELENA, MT 59601 | 406-XXX-XXXX | Yes |
A monthly Team Care enrollee list, which includes the member’s lock-in pharmacy, accompanies the provider’s Passport enrollee list, as applicable.
| Team Care Enrolled Client List | |||||||
|---|---|---|---|---|---|---|---|
| Client Name | Medicaid ID |
Birth Date | Address | Phone | New Enrollee |
Provider | Pharmacy |
| GUNDER, HANS | XXXXXXXXX | 5/30/1980 | PO BOX 1584, HELENA, MT 59601 |
406-XXX-XXXX | No | ST PETERS HEALTH | CVS PHARMACY |
| IMSEN, RAGA | XXXXXXXXX | 2/7/1969 | 822 HENRY ST, HELENA, MT 59601 |
406-XXX-XXXX | Yes | ST PETERS HEALTH | ALBERTSONS LLC |
| LANTZ, SUNNY | XXXXXXXXX | 11/11/2000 | 677 1ST ST, HELENA, MT 59601 |
406-XXX-XXXX | No | ST PETERS HEALTH | WALMART INC |
PCMH and CPC+ providers access Member Registries through HealtheRegistries tool. In order to gain access to HealtheRegistries create a login on the Montana Healthcare Programs ICAP Portal (healthinteractive.net) and request access to registries and analytics. You will be contacted by DPHHS for management approval and to provide training.
Most Montana Medicaid/HMK Plus members are required to enroll in Passport to Health. Members who are not required to enroll in Passport are considered either exempt or ineligible. If participation in Passport causes a medical hardship, members may petition the state for an exempt status.
The Office of Public Assistance determines Montana Medicaid/HMK Plus eligibility. If the member’s eligibility requires them to participate in Passport, the information is sent to the Passport to Health enrollment broker, who begins member enrollment and education.
New members receive an enrollment packet containing the following information:
Members of a family may have the same Passport provider, or everyone can have a different Passport provider based on individual needs. Members are not auto-assigned to a Passport provider unless they have not chosen a provider themselves. Members receive a reminder letter, an outreach call, and are given 45 days to select a provider. After 45 days, Passport to Health automatically assign members to a provider appropriate to the member's age, sex, and location based on the following criteria (in order):
Members who are assigned to a Passport provider are notified at least 10 days in advance of the effective assignment date to allow members to notify Passport to Health if they would like to select a different provider.
Members may change their Passport provider up to once per month but the change will not be effective until the beginning of the following month at the earliest, depending on the date the choice is made. (ARM 37.86.5103-5104)
In addition to the enrollment packet, all families with an active telephone number receive up to 3 telephone attempts to verbally explain Montana Medicaid/HMK Plus benefits and the Passport program, answer questions, and take enrollment information over the telephone.
An education script is followed during these outreach calls to ensure that all members receive the same information about Montana Medicaid/HMK Plus and Passport. Members have additional resources to help them use their Montana Medicaid/HMK Plus services and understand the Passport to Health program.
Member Education Resources
| Resource | Description | Where to Find |
|---|---|---|
| Montana Healthcare Programs Member Help Line | The toll-free Montana Healthcare Programs Member Help Line is available to answer members’ questions and enroll them with a PCP. The Help Line may direct members to other Montana Medicaid/HMK Plus resources or entities. | Montana Healthcare Programs Member Help Line, (800) 362-8312 |
|
Montana Medicaid/HMK Plus Member Guide |
All eligible Montana Medicaid/HMK Plus members are sent a postcard informing them how to find the Member Guide online or how to request a paper copy. This guide, which includes a section on the Passport program, is an excellent resource for members enrolled in Montana Medicaid/HMK Plus. | Call the Montana Healthcare Programs Member Services Help Line (800) 362-8312 to request a copy of the Member Guide or go to DPHHS Member Services Website. |
| Preventive Materials | Preventive healthcare letters are mailed yearly to youth with HMK Plus just before their birthday. The mailing includes an immunization and well-child exam schedule. The schedule is also available on our website. | DPHHS Well Child Website |
DPHHS requires Montana Medicaid/HMK Plus members to enroll and participate in the Passport program, unless exempt from or ineligible for participation.
Members Ineligible for Passport
DPHHS has determined the following categories of members are not eligible to participate in the Passport program:
Members Exempt from Passport
DPHHS has determined members who are eligible to participate in the Passport program may request an exempt status for the following reasons:
DPHHS has the discretion to determine hardship and to place time limits on all exemptions on a case-by-case basis. Members who are exempt from participation may elect to re-enroll in the Passport to Health program at a later time.
Passport referral is needed for most medically necessary services that the member’s Passport provider does not provide. Referrals can be made to any other provider who accepts Montana Medicaid/HMK Plus. Referrals can be verbal or written, and must be accompanied by the provider’s Passport referral number. Providers are required to keep a paper or electronic log of all Passport referrals given or received in the member’s records, a spreadsheet, or other record. The Passport provider establishes the parameters of referrals, which may be for a one-time visit, a time specific period, or the duration of a condition. An optional referral form is available on the Provider Information website.
If a provider sees a member for a routine visit or sees the member frequently and is not that member’s Passport provider, the provider should talk to the member about the importance of having a medical home. Additionally, providers should also talk to Team Care members about the importance of using the same pharmacy for prescriptions. Also discuss the importance of receiving the right care at the right time at the right place. Members need to receive regular care and not use emergency care when not absolutely necessary.
It is acceptable to deny service if the member is able to see their Passport provider. Conversely, the Passport provider is under no obligation to provide a referral if the member is able to see them. Suggest to the member that they see their Passport provider every time they are sick or hurt. It is also acceptable to suggest that the member changes to your clinic as their Passport provider. To change their provider, the member can call the Montana Healthcare Programs Member Help Line from your office or have the provider fax a Passport Provider Change Form (available on the Passport page of the Provider Information Website) signed by the member.
Providers should obtain a Passport referral in advance, and specific to services and dates. If a provider accepts a member as a Montana Medicaid/HMK Plus member and provides a service requiring a Passport referral without the member’s Passport provider’s referral, Montana Medicaid/HMK Plus will deny the claim. When a provider bills Montana Medicaid/HMK Plus for services rendered to a member, the provider has accepted the member as a Montana Medicaid/HMK Plus member and cannot bill the member for services. If a provider tried unsuccessfully to get approval from the PCP, the provider cannot bill the member unless the member agreed to pay privately before services were rendered. (ARM 37.85.406)
Passport referrals and prior authorization are different. For more information, see the Additional Passport Information chapter in this manual and Prior Authorization chapters in your provider type manual and the General Information for Providers Manual.
Establishing care with a provider helps ensure Montana Medicaid/HMK Plus members receive effective, quality medical care. The Passport program recommends that in most cases, Passport referrals should not be given to specialists or other PCPs if the member has not established care with their PCP. In most cases, care should start with and be coordinated by the Passport PCP. Encourage the member to establish a relationship with their PCP for services.
If a provider consistently receives requests for referrals for a member that the provider has never seen, it is acceptable for the provider to disenroll the member from their Passport caseload. It is also acceptable to disenroll established members who are consistently seeking primary care elsewhere or specialty care that requires provider referral. See the Disenrolling Passport or Team Care Members chapter in this manual for more details.
There are some instances where the Passport program requests that the Passport PCP provide a referral, even when care has not been established. The member’s access to care, whether or not the member has established care, is a responsibility of the member’s PCP.
A referral determination should be based on whether it is reasonable for the PCP to provide, and the member to access care in a specific situation. Some examples in which referrals are needed in order to ensure access to needed care are:
Important note: This is not an all inclusive list.
Members must obtain services directly from or through a Passport referral, except for:
The Indian Health Service (IHS) is the health care system for federally recognized American Indian and Alaska Natives (AI/AN). When AI/AN are eligible for Montana Medicaid/HMK Plus, it will pay for services provided through an IHS as well as other Montana Medicaid/HMK Plus providers. An AI/AN Montana Medicaid/HMK Plus member who is enrolled in Passport to Health may choose an IHS to be the primary care provider if the IHS is a Passport provider. The member may alternatively choose a Passport provider other than an IHS. If the member chooses a Passport provider other than an IHS, they may go to an IHS as well without a referral from the Passport provider.
Passport and Team Care referrals for a Medicaid member designated AI/AN in the Medicaid system are not required when the member is visiting an Indian Health Service Unit, Tribal 638 Facility, or Urban Indian Health Center (I/T/U).
Passport and Team Care referral is not required when an I/T/U refers an AI/AN member to a provider who is not their designated Passport provider or Team Care provider. The non-I/T/U provider will be required to have the I/T/U’s NPI present in field 17a on a CMS-1500 or field 7 on a UB-04 or claims will be denied.
EPSDT is a benefit package for all HMK Plus members designed to ensure that children receive comprehensive healthcare. The provider is encouraged to actively screen for specific pediatric problems, order diagnostic tests as indicated, and treat problems found, or if necessary, refer members to other providers for treatment.
All children should have regular well-child checkups beginning at birth and through age 20. The Passport program sends reminders to Passport members advising them that they are due for a well-child checkup.
The Passport program encourages providers to conduct well-child checkups according to a specific schedule.
Montana Healthcare Programs has adopted the Bright Futures/American Academy of Pediatrics periodicity schedule. The national schedule can be found at brightfutures.aap.org. In addition to these scheduled visits, well-child screenings should be incorporated into every visit if possible.
Well-child checkups include the following:
If a screening indicates the need for further diagnostic testing or treatment, those services should be provided without delay. If the service cannot be provided by the Passport provider, a referral must be made.
Montana Medicaid/HMK Plus covers all services that are determined to be medically necessary to members under age 21, even if those services are not covered for adults. Examples of additional services for pediatric members include chiropractic treatment, nutrition, private duty nursing, residential treatment, respiratory therapy, school-based services, and substance use disorder inpatient and day treatment.
Reimbursement for Passport member services are the same as Montana Medicaid/HMK Plus fee-for-service reimbursement. This allows providers the opportunity to become actively involved in cost containment and quality of care without financial risk. For more information on reimbursement, see your provider type fee schedule available on the Provider Information website.
In addition to fee-for-service reimbursement, Passport providers receive a monthly case management fee as defined below:
| Passport | $1 for regular Passport members $3 for aged, blind, and disabled members |
|---|---|
| Team Care | $6 for member's enrolled with the basic Passport providers |
| PCMH | Tier 1: $3.33 Tier 2: $9.33 Tier 3: $15.33 Tier 4: $470.10 (CCM Tier) Note: PCMH providers are reimbursed for Team Care members based on the member's assigned tier. |
| CPC+ Track 1 | Tier 1: $3.33 Tier 2: $9.33 Tier 3: $15.33 Tier 4: $21.33 Note: CPC+ providers are reimbursed for Team Care members based on the member's assigned tier. |
| CPC+ Track 2 | Tier 1: $6.33 Tier 2: $12.33 Tier 3: $18.33 Tier 4: $24.33 Tier 5: $34.33 Note: CPC+ providers are reimbursed for Team Care members based on the member's assigned tier. |
This PMPM fee is in a separate payment from the fee-for-service reimbursement and is paid regardless of whether the member is seen during the month. The monthly case management fee is paid with the expectation that the items listed in the provider requirements of this manual are completed as needed for member’s coordination of care. The monthly case management fee is paid to providers by their Passport number.
The fees are listed with the appropriate procedure code for each PCCM enrollee on the provider’s remittance advice. The date of service for the code is shown as the first of the month for which the fee is being paid. Each Passport companion program has their own procedure codes provided below:
| PCCM Program | Procedure Code |
|---|---|
| Passport | G9008 |
| Team Care | G9008 |
| PCMH | G9012 |
| CPC+ Track 1 and Track 2 | G9005 |
| T-HIP | T2022 |
Verify member's eligibility and Passport provider at each visit before treating the member. Contact Provider Relations for information on Montana Medicaid/HMK Plus claims.
Do not bill for case management fees; they are paid automatically to the provider each month. Team Care is a component of the Passport program; therefore, Team Care billing procedures are the same as Passport. Link your Passport to your submitter number to ensure that case management fee appear on your remittance advices.
For additional instructions on billing Montana Medicaid/HMK Plus, refer to your provider type manual.
The Passport referral number is the number the PCP gives to providers when approving services. This is a number issued to the Passport provider and must be on the requesting provider’s claim or Montana Medicaid/HMK Plus will deny the service if it requires a Passport referral.
The Passport referral number is recorded in Box 17a on a CMS-1500 claim and Box 7 on a UB-04 claim. The referring provider’s NPI is not required.
Passport and Team Care referral is not required when an I/T/U refers an American Indian/Alaska Native (AI/AN) member to a provider who is not their designated Passport provider or Team Care provider. The non-I/T/U provider will be required to have the I/T/U’s NPI present in field 17a on a CMS-1500 or field 7 on a UB-04 or claims will be denied.
To bill a Montana Medicaid/HMK Plus member, an agreement must be signed by the member in advance of services. There are two types of member agreements:
Providers may not bill a member when the provider has informed the member that Montana Medicaid/HMK Plus may not pay or when the agreement is contained in a form that provider routinely requires members to sign. Members may be billed for:
Providers are required to accept the amount paid by Montana Medicaid/HMK Plus as payment in full. Unless an agreement is signed, members may not be billed for:
When a member is accepted as a Montana Medicaid/HMK Plus member in a service setting (e.g., facility, institution), all other providers performing services for the member will be deemed to have accepted the member as a Montana Medicaid/HMK Plus member.
Acceptance of a member as a Montana Medicaid/HMK Plus member applies to all services provided by the provider. A provider may not accept Montana Medicaid/HMK Plus for some covered services but refuse Montana Medicaid/HMK Plus for other covered services.
If a member has agreed prior to services that payment will be made from a source other than Montana Medicaid/HMK Plus but is later determined retroactively eligible for Montana Medicaid/HMK Plus, the provider may choose to accept the individual as Montana Medicaid/HMK Plus or seek payment in accordance with the original payment agreement.
A provider who bills Montana Medicaid/HMK Plus for services will be deemed to have accepted the member as Montana Medicaid/HMK Plus.
Bills owed to a provider do not affect the Passport relationship. A member may not be denied services or be disenrolled by the Passport provider due to unpaid bills. (ARM 37.86.402)
A provider may disenroll a Passport or Team Care member for the following reasons:
A provider cannot disenroll a Passport or Team Care member for the following reasons:
A written disenrollment notification must be sent to the member and Conduent by providing 30 days' notice.
Verbal notification to the member does not constitute disenrollment; the provider remains responsible for the care of the member until the disenrollment process is complete.
Reasons for disenrollment must be explained in writing, must be non-discriminatory, must be generally applied to the provider’s entire patient base. Please use the PCCM Member Disenrollment Form on the Passport page of the Provider Information Website.
A copy of the member’s disenrollment notification must be mailed or faxed to the Conduent Passport to Health Analyst. During these 30 days, the provider must continue to treat the member or refer the member to another provider. The provider is responsible for serving the Passport member for 30 days after the submission of the disenrollment to the Conduent Passport Provider Analyst. The Passport Provider Analyst cannot make exceptions. DPHHS may allow exceptions under rare circumstances.
Providers may call the Conduent Passport Provider Analyst with questions about the disenrollment process. The Passport program will not disenroll members from a PCP without written notification from the provider. The Montana Healthcare Programs Member Help Line will assist the member in selecting a new PCP.
Formal complaints filed against a provider or healthcare facility for improper care or unsafe conditions will be forwarded to the proper state licensing agency. Informal member complaints or grievances about healthcare services rendered by a provider or professional will be forwarded to the program officer with knowledge of the program. Informal member complaints will be addressed by the program officer within 7 business days.
If a provider believes DPHHS has made a decision that fails to comply with applicable laws, regulations, rules, or policies, the provider may request an administrative review or fair hearing. Requests must be addressed to the Office of Fair Hearings. A copy must also be delivered or mailed to the division that issued the contested determination.
To request an administrative review, state in writing the objections to the decision made by DPHHS and include substantiating documentation for consideration in the review.
DPHHS must receive the request within 30 days from the date the initial determination from DPHHS was mailed. Providers may request extensions in writing within these 30 days. If the provider is not satisfied with the DPHHS administrative review results, a fair hearing may be requested. Fair hearing requests must contain concise reasons the provider believes the DPHHS administrative review determination fails to comply with applicable laws, regulations, rules, or policies. This document must be signed and received by the Office of Fair Hearings within 30 days from the date DPHHS mailed the administrative review determination.
Providers shall not discriminate illegally in the provision of service to eligible Medicaid recipients or in employment of persons on the grounds of race, creed, religion, color, sex, national origin, political ideas, marital status, age, or disability.
Discrimination may not occur regarding admission to, participation in, or receipt of services or benefits of any of its programs, activities, or employment, whether carried out by DPHHS or through a contractor or other entity. In case of questions or in the event that you wish to file a complaint alleging violations, contact DPHHS, Office of Human Resources.
If you wish to file a complaint with the Office of Civil Rights, contact them at the address or telephone number on the Contact Us page of the Provider Information website. A person does not have to go through the administrative review or fair hearing process to file a complaint with the Office for Civil Rights.
The Passport forms listed below are found on the Passport page (mt.gov) and others are available on the Forms page (mt.gov) of the Provider Information website.
The forms listed below are found on the Forms or Passport to Health pages of the Montana Healthcare Programs Provider Information website.
Passport to Health- https://medicaidprovider.mt.gov/passport
This section contains definitions and acronyms specific to Passport provider. Additional definitions and acronyms are found on the Definitions and Acronyms page of the Provider Information website.
A group Passport provider is enrolled in the program as having one or more Montana Medicaid/HMK Plus providers practicing under one Passport number.
A solo Passport provider is enrolled in the program as an individual provider with one Passport number.
A well-child checkup is an important way to monitor growth and development of young members. Regular checkups provide an opportunity for providers to develop a strong relationship with their members.
This edition has three search options.
1. Search the whole manual. Open the Complete Manual pane. From your keyboard press the Ctrl and F keys at the same time. A search box will appear. Type in a descriptive or key word (for example "Denials"). The search box will show all locations where denials are discussed in the manual.
2. Search by Chapter. Open any Chapter tab (for example the "Billing Procedures" tab). From your keyboard press the Ctrl and F keys at the same time. A search box will appear. Type in a descriptive or key word (for example "Denials"). The search box will show where denials are discussed in just that chapter.
3. Site Search. Search the manual as well as other documents related to a particular search term on the Montana Healthcare Programs Site Specific Search page.
This publication supersedes all previous Passport to Health (Passport) guides and manuals. First published by the Department of Public Health and Human Services (DPHHS), December 2003.
Updated September 2004, September 2005, March 2008, May 2009, September 2013, August 2015, November 2015, September 2017, January 2019, January 2020, March 2022, March 2023, and June 2023.
CPT codes, descriptions, and other data are under copyright and are from the American Medical Association’s most current CPT manual published. All Rights Reserved. Applicable FARS/DFARS apply.
06/01/2023
04/14/2023
Updated entire manual.
04/01/2022
01/01/2020
01/18/2019
Updated whole manual with current terms, programs, policies, and links.
09/29/2017
Passport to Health Manual converted to an HTML format and adapted to 508 Accessibility Standards.
11/09/2015
Passport to Health, November 2015: Passport Referrals
Contact hours are 8 a.m. to 5 p.m. Monday–Friday Mountain Time unless otherwise stated.
The numbers designated TDD and TYY have a telecommunication device for people who need assistance hearing. Persons with disabilities who need an alternative accessible format of this information, or who require some other reasonable accommodation to participate in Montana Medicaid/HMK Plus, should contact DPHHS through the Passport to Health program.
IHS/Tribal Program Officer
Health Resources Division (HRD)
DPHHS
P.O. Box 202951
Helena, MT 59620-2951
(406) 444-4540
(406) 444-1861 Fax
To request a fair hearing or administrative review, email hhsofh@mt.gov or mail the request to the address below:
Office of Fair Hearings
DPHHS
P.O. Box 202953
Helena MT 59620-2953
(406) 444-2470
For forms and information on providing interpretive services to members, call the Montana Medicaid/HMK Plus at (406) 444-4540.
Telecommunications assistance for the hearing impaired.
Montana Relay Services Email: relay@mt.gov
(800) 833-8503 Voice, TTY
(406) 444-1335 Voice, TTY
For complaints about alleged discrimination because of race, color, national origin, age or disability, or other protected classes. Hours are 8 a.m. to 4 p.m. Mountain Time.
(406) 444-0262
Member Complaint Coordinator
Office of Human Resources
DPHHS
P.O. Box 4210
Helena, MT 59620-4210
(800) 368-1019
(800) 537-7697 TDD
Members who have Medicaid/HMK Plus questions, are looking for a provider, or want to choose a Passport provider may call the Montana Healthcare Programs Member Help Line:
(800) 362-8312
Providers with questions regarding Passport may contact the Conduent Passport Provider Analyst or the Passport Program Officer.
Conduent Passport Provider Analyst
(406) 457-9542
(406) 442-2328 Fax
Passport to Health Program
P.O. Box 254
Helena MT 59624-0254
Passport Program Officer
Providers who have policy or program questions and concerns or need to report errors, omission, or discrepancies in member utilization and cost reports may contact the Passport program officer.
(406) 444-4540
(406) 444-1861 Fax
Passport Program Officer
Member Health Management Bureau
P.O. Box 202951
Helena MT 59620-2951
For questions regarding the Team Care Program:
(406) 444-4540
(406) 444-1861 Fax
Team Care Program Officer
Member Health Management Bureau
P.O. Box 202951
Helena MT 59620-2951
Passport to Health (Passport) is the primary care case management (PCCM) program for the following Montana Healthcare Programs: Standard Medicaid, HELP Program/Medicaid Expansion, and Healthy Montana Kids Plus. The Passport to Health program provides case management related services that include locating, coordinating, and monitoring primary healthcare services. To achieve this, the Passport program works with the state’s other care coordination programs:
Montana Medicaid and HMK Plus members who are eligible for Passport must enroll in the program. See the Member Enrollment and Eligibility Chapter of this manual for a list of members who are ineligible for Passport. Each member has a designated Passport provider such as a physician, mid-level practitioner, or primary care clinic.
The Passport provider delivers PCCM services to their members. This means they provide or coordinate the member’s care and make referrals to other Montana Healthcare Programs providers when necessary. The member’s Passport provider is also referred to as the primary care provider (PCP).
Most services provided to Passport members must be provided by or referred by the member’s Passport provider. Other Medicaid providers will not be reimbursed for their services without a Passport provider's referral.
The Agency for Healthcare Research and Quality (AHRQ) defines care coordination as “deliberately organizing [member] care activities and sharing information among all of the participants concerned with a [member's] care to achieve safer and more effective care. This means that the [member’s] needs and preferences are known ahead of time and communicated at the right time to the right people, and that this information is used to provide safe, appropriate, and effective care to the [member].”
The PCCM model facilitates a strong member–provider relationship by providing primary, preventive, and routine services; managing and coordinating the member’s services; and acting as the front door to Montana Medicaid/HMK Plus services. To be an effective PCP, a provider’s office or facility must be:
Providers must be familiar with all current rules and regulations governing the Montana Medicaid/HMK Plus program. Provider manuals assist providers in billing Montana Medicaid/ HMK Plus; they do not contain all Montana Medicaid rules and regulations. Rule citations in the text are a reference tool; they are not a summary of the entire rule. Administrative Rules of Montana may be found at Administrative Rules of the State of Montana (mt.gov).
Paper copies of rules are available through the Secretary of State’s office. In addition to the general Montana Medicaid rules outlined in the General Information for Providers Manual and the rules outlined in each program manual, the following rules and regulations are also applicable to the Passport to Health program:
The Member Health Management Bureau (MHMB), a part of the Health Resources Division (HRD) of DPHHS, administers the Passport program and its ancillary programs: Team Care, PCMH, and CPC+. The MHMB determines services and policy regarding these programs. Manuals and other information are available on the Provider Information website.
The Montana Healthcare Programs Member Help Line assists members with Passport provider enrollment, helps them locate or change providers, and answers their Montana Medicaid/ HMK Plus and Passport questions. Additionally, the Montana Healthcare Programs Member Help Line assists pharmacies and Team Care members with pharmacy unlocks.
Provider Relations answers provider questions about Montana Healthcare Programs services, claims, and eligibility, and addresses provider concerns.
Providers may also call the Conduent Passport Provider Analyst to discuss problems or questions regarding Passport members or to enroll in Passport. See the Key Contacts and Websites chapter in this manual.
Providers should keep up with changes and updates to the Passport program by reading the Claim Jumper, Montana Healthcare Program’s monthly online newsletter, and any Passport provider notices issued.
A PCP can be a physician or a mid-level practitioner who provides PCCM services by agreement with DPHHS. DPHHS allows any provider who has primary care within their professional scope of practice to be a PCP. However, DPHHS does recognize that certain specialties are more likely to practice primary care, and actively recruits these providers.
To enroll in Passport, Montana Medicaid/HMK Plus providers must meet the following requirements. (ARM 37.86.5111)
The Passport provider agreement and this manual are available on the Passport page of the Provider Information website. Providers may also call the Conduent Passport Provider Analyst for information on becoming a Passport provider and to get the Passport provider agreement.
Solo Passport Provider
A solo Passport provider is enrolled in the program as an individual provider with one Passport number. The solo provider is listed as the member’s Passport provider. The solo provider is responsible for managing his or her individual Passport caseload. For details on referral documentation, see the Passport Referral chapter in this manual. Case management fees are paid to the individual provider under the solo provider’s Passport number in addition to the fee-for-service reimbursement.
Group Passport Provider
A group Passport provider is enrolled in the program as having one or more Montana Medicaid/HMK Plus providers practicing with one Passport number. The group name will be listed as the member’s Passport provider and could be a private group clinic, Rural Health Clinic, Federally Qualified Health Center, or Indian Health Service (IHS) clinic. All participating providers sign the Passport agreement group signature page and are responsible for managing the caseload. With a group provider, members may visit any provider within the group practice without a Passport referral. Case management fees are paid to a group under the group Passport number in addition to the fee-for-service reimbursement.
Passport providers must provide or arrange for suitable coverage for needed services, consultation, and approval or denial of referrals during posted normal business hours. If another provider is covering, the covering provider need not be enrolled as a Passport provider, but must be a Montana Medicaid/HMK Plus provider. Coverage can be provided by a physician, physician's assistant, or advanced practice registered nurse. The covering provider must have permission from the member's Passport provider number for claims.
Posted Normal Office Hours Coverage
May consist of a receptionist or equivalent, telephone system that will get the member to medical staff, or any appropriate method that provides the member access to the PCP or someone who can make medical decisions.
24-Hour Coverage
Passport providers must provide direction to members in need of emergency care 24/7/365. Acceptable direction includes an answering service, call forwarding, provider on-call coverage, or answering machine message. When a message is used, it should state at a minimum: If this is a medical emergency, hang up and either call 911 or go to the emergency department. Passport providers are required to provide education to their members regarding the appropriate use of the emergency department.
Vacation, Illness, and Other Absences
During periods of absence, providers must arrange for coverage for posted normal office hours as specified above. Passport members must have access to services or referrals from the covering provider(s).
Inability to Perform Services
Solo Passport providers are required to let DPHHS know if they are unable to fulfill their Passport to Health duties. If they cease to fulfill their Passport agreement and fail to arrange for other coverage, the member's will be disenrolled to the beginning of the month in which the provider was unable to make appropriate arrangements.
If the provider’s office provides documentation that coverage arrangements were made in advance, their members will not be disenrolled for a reasonable time. In such instances, DPHHS will work closely with the provider's office to determine if the condition will be long term and will require disenrollment.
Members will not be disenrolled from a group Passport provider if one provider becomes unable to provide or refer members for services as the remaining providers in the group shall provide the required PCCM coverage.
Passport providers may not distribute any marketing materials without first obtaining approval from DPHHS. Any marketing plans must also be submitted to DPHHS for prior written approval. Providers may not conduct direct or indirect marketing activities that are intended to influence members to enroll with the PCP or disenroll from another PCP.
There are no caseload limits, but there are minimums:
Passport providers who reach their caseload capacity have the opportunity to increase capacity by a minimum of 10% or more in order to have more Passport members choose or be assigned to them.
Providers must notify Provider Relations in writing within 30 days of changes that include the following:
When a provider wishes to terminate their Passport to Health enrollment, DPHHS requires a written notification at least 30 days in advance of the desired termination or removal date. Written notification is sent to Provider Relations. It is important to also give members at least 30 days' notice before termination to allow them enough time to choose another Passport provider. To ensure continuity of care during these 30 days, the provider must continue to treat the members or refer them to another provider.
Passport providers are subject to utilization review to verify the care and services provided through the program are fulfilling the requirements of the Passport provider agreement. (ARM 37.86.5111)
Team Care is a companion program of Passport to Health designed to educate members how to appropriately and effectively access medical care. Members enrolled in Team Care are also enrolled in Passport. Enrollment in Team Care is based on utilization that is found to be excessive, inappropriate, or fraudulent with respect to need. Montana Medicaid/HMK Plus members can be referred to Team Care by Drug Utilization Review Clinical Case Managers, PCPs, pharmacists, hospitals, or from claims data mining.
Team Care follows the same Passport rules and guidelines for referrals, enrollment/disenrollment, prior authorization, and billing processes. However, members enrolled in Team Care are restricted to one pharmacy.
When checking Montana Medicaid/HMK Plus eligibility, a Team Care member's provider and pharmacy will be listed. Providers must write all Montana Medicaid/HMK Plus prescriptions to the designated pharmacy. (ARM 37.86.5303)
Providers are encouraged to make a referral to the Team Care Program Officer if they feel one of their members is appropriate for the program. A Passport provider receives a case management fee of $6 per member per month (PMPM) for Team Care members. Passport providers are enrolled in either PCMH or CPC+ will receive a tiered PMPM payment for their attributed Team Care members based on the member's risk as described in the sections below.
Patient Centered Medical Home (PCMH) is a companion program of Passport to Health designed to support providers who have reached National Committee for Quality Assurance (NCQA) PCMH certification.
PCMH is a medical home model of care that offers a way to improve healthcare by transforming how primary care is standardized and delivered. The PCMH model of care is based on the following core principles:
Providers contract with DPHHS to provide PCMH care management services and receive increased PMPM care management fees based on the member’s risk score. Members are assigned a health risk score based on their score of potential risk across the entire population and are divided into three tiers. The care management fee amount corresponds to the risk-tier level.
Tier PMPM rates
PCMH providers have the option to participate in Tier 4, Complex Care Management (CCM). The purpose of CCM tier is to partner with PCMH providers to reduce costly services for Medicaid members with high utilization of emergency department visits and hospital admissions that might have been prevented by less costly interventions and primary care. The CCM program is aimed at working with Medicaid members in their homes to improve the health of members with high utilization by focusing on both medical and non-medical factors that may be impacting the member’s health.
Providers are reimbursed $470.10 per member per month for members actively enrolled in PCMH Tier 4 CCM.
PCMH providers enrolled in Tier 4 CCM must meet the following criteria:
Members must meet specific requirements to be enrolled in Tier 4 CCM including:
PCMH providers report quality measures annually to DPHHS. Medicaid merges claims data with the providers’ clinical data for each measure to determine performance rates for each measure. The quality measures include preventive services and utilization elements.
The PCMH program follows the same Passport rules and guidelines for referrals, enrollment/disenrollment, prior authorization, and billing processes. Practices must maintain PCMH recognition by the NCQA.
Providers wishing to enroll in the PCMH program should contact the Passport Program Officer to request additional details.
Comprehensive Primary Care Plus (CPC+) is a companion program of Passport to Health. CPC+ is an initiative developed by CMS with the goal to transition fee-for-service to value-based payments in collaboration with commercial payers in selected regions.
CPC+ payer partners and providers are collaborating around the goals of smarter healthcare spending, more effective healthcare delivery, and healthier patients.
For the purposes of the CPC+ Initiative, Montana Medicaid will only contract with primary care practices other than Federally Qualified Health Centers and Rural Health Clinics that meet at least one of the following criteria:
The program includes Track 1 and Track 2 practices; Track 2 practices have additional care delivery requirements including:
Providers contract with DPHHS to provide CPC+ care management services and are reimbursed risk-stratified, PMPM care management fees. Members are assigned a health risk score based on their score of potential risk across the entire population and are divided into tiers based on the provider track.
| Track 1 | PMPM Fee | Track 2 | PMPM Fee |
|---|---|---|---|
| Tier 1 | $3.33 | Tier 1 | $6.33 |
| Tier 2 | $9.33 | Tier 2 | $12.33 |
| Tier 3 | $15.33 | Tier 3 | $18.33 |
| Tier 4 | $21.33 | Tier 4 | $24.33 |
| Tier 5 | $34.33 |
CPC+ providers report quality measures annually to DPHHS. DPHHS merges claims data with the providers’ clinical data for each measure to determine performance rates for each measure. The quality measures include preventive services and utilization elements. Providers are eligible for annual quality incentive payments for meeting quality measure benchmarks.
CPC+ program follows the same Passport rules and guidelines for referrals, enrollment/ disenrollment, prior authorization, and billing processes.
Providers wishing to enroll in the CPC+ program should contact the Passport Program Officer to request additional details.
The Tribal Health Improvement Program (T-HIP) is a historic partnership between the Tribal, State and Federal governments to address factors that contribute to health disparities in the American Indian population eligible for Montana Medicaid/HMK Plus and residing on a reservation.
T-HIP services are designed to help members:
T-HIP is a three-tier program administered by a federally recognized tribe. A tribe may choose which level they wish to participate at. Implementation of Tier 1 is mandatory prior to participating in Tier 2 and Tier 3. Tier 1 focuses on high-risk, high-cost members identified by DPHHS. Services provided under Tier 1 seek to improve the health of members who have chronic illnesses or are at risk of developing serious health conditions through intensive care coordination of individual members. The services in Tier 1 also seek to enhance the communication and coordination link between the member and the Passport PCP. In addition to Tier 1 there are two other Tier choices. Tier 2 and Tier 3 address specific health focus areas that contribute to health disparities.
Passport referral and prior authorization are different. Passport referral is a referral to visit another provider; prior authorization refers to a list of services that require DPHHS authorization before they are performed. Some services may require a Passport referral and/or prior authorization. Passport referral is obtained by contacting the member's Passport provider. Prior authorization is obtained through a DPHHS contractor, Mountain-Pacific Quality Health (MPQH).
In addition, Passport referral reinforces a member's medical home relationship, but does not take the place of required written chart order for therapy services. See ARM 37.86.606(3)(a).
Different numbers are issued for Passport referral and prior authorization, and if required, both numbers must be listed on the requesting provider's claim. For more information on prior authorization, see the Prior Authorization chapter in the General Information for Providers Manual, your provider type manual, and the Prior Authorization page on the Provider Information website.
Copayments are not assessed for Medicaid or Healthy Montana Kids Plus members.
Service limits are the same for Passport members and non-Passport members. For more information on service limits, see the Montana Healthcare Programs billing manual for your provider type and the General Information for Providers Manual, both available on the Provider Information website.
A monthly Passport enrollee list is sent to each Passport provider by the first day of each month to assist Passport providers in managing their Passport members. Below is a sample enrollee list.
Providers should contact new members to set up an appointment to establish care and introduce new members to their practice, office policies, and staff. If a member has been on a provider’s list before but is shown as a new member, he/she may have lost Montana Medicaid/HMK Plus eligibility for a period of time.
| Passport Enrolled Client List | |||||
|---|---|---|---|---|---|
| Client Name | Medicaid ID |
Birth Date | Address | Phone | New Enrollee |
| GUNDER, HANS | XXXXXXXXX | 5/30/1980 | PO BOX 1584 HELENA, MT 59601 | 406-XXX-XXXX | No |
| IMSEN, RAGA | XXXXXXXXX | 2/7/1969 | 822 HENRY ST, HELENA, MT 59601 | 406-XXX-XXXX | Yes |
| LANTZ, SUNNY | XXXXXXXXX | 11/11/2000 | 677 1ST ST, HELENA, MT 59601 | 406-XXX-XXXX | No |
| OSTER, FELIX | XXXXXXXXX | 12/4/1989 | 11 SADDLE RD, HELENA, MT 59601 | 406-XXX-XXXX | No |
| POLLY, PENNY | XXXXXXXXX | 9/15/1976 | 27 MAIN ST, HELENA, MT 59601 | 406-XXX-XXXX | No |
| TURNER, SAM | XXXXXXXXX | 4/29/1955 | 646 STURN LN, HELENA, MT 59601 | 406-XXX-XXXX | Yes |
A monthly Team Care enrollee list, which includes the member’s lock-in pharmacy, accompanies the provider’s Passport enrollee list, as applicable.
| Team Care Enrolled Client List | |||||||
|---|---|---|---|---|---|---|---|
| Client Name | Medicaid ID |
Birth Date | Address | Phone | New Enrollee |
Provider | Pharmacy |
| GUNDER, HANS | XXXXXXXXX | 5/30/1980 | PO BOX 1584, HELENA, MT 59601 |
406-XXX-XXXX | No | ST PETERS HEALTH | CVS PHARMACY |
| IMSEN, RAGA | XXXXXXXXX | 2/7/1969 | 822 HENRY ST, HELENA, MT 59601 |
406-XXX-XXXX | Yes | ST PETERS HEALTH | ALBERTSONS LLC |
| LANTZ, SUNNY | XXXXXXXXX | 11/11/2000 | 677 1ST ST, HELENA, MT 59601 |
406-XXX-XXXX | No | ST PETERS HEALTH | WALMART INC |
PCMH and CPC+ providers access Member Registries through HealtheRegistries tool. In order to gain access to HealtheRegistries create a login on the Montana Healthcare Programs ICAP Portal (healthinteractive.net) and request access to registries and analytics. You will be contacted by DPHHS for management approval and to provide training.
Most Montana Medicaid/HMK Plus members are required to enroll in Passport to Health. Members who are not required to enroll in Passport are considered either exempt or ineligible. If participation in Passport causes a medical hardship, members may petition the state for an exempt status.
The Office of Public Assistance determines Montana Medicaid/HMK Plus eligibility. If the member’s eligibility requires them to participate in Passport, the information is sent to the Passport to Health enrollment broker, who begins member enrollment and education.
New members receive an enrollment packet containing the following information:
Members of a family may have the same Passport provider, or everyone can have a different Passport provider based on individual needs. Members are not auto-assigned to a Passport provider unless they have not chosen a provider themselves. Members receive a reminder letter, an outreach call, and are given 45 days to select a provider. After 45 days, Passport to Health automatically assign members to a provider appropriate to the member's age, sex, and location based on the following criteria (in order):
Members who are assigned to a Passport provider are notified at least 10 days in advance of the effective assignment date to allow members to notify Passport to Health if they would like to select a different provider.
Members may change their Passport provider up to once per month but the change will not be effective until the beginning of the following month at the earliest, depending on the date the choice is made. (ARM 37.86.5103-5104)
In addition to the enrollment packet, all families with an active telephone number receive up to 3 telephone attempts to verbally explain Montana Medicaid/HMK Plus benefits and the Passport program, answer questions, and take enrollment information over the telephone.
An education script is followed during these outreach calls to ensure that all members receive the same information about Montana Medicaid/HMK Plus and Passport. Members have additional resources to help them use their Montana Medicaid/HMK Plus services and understand the Passport to Health program.
Member Education Resources
| Resource | Description | Where to Find |
|---|---|---|
| Montana Healthcare Programs Member Help Line | The toll-free Montana Healthcare Programs Member Help Line is available to answer members’ questions and enroll them with a PCP. The Help Line may direct members to other Montana Medicaid/HMK Plus resources or entities. | Montana Healthcare Programs Member Help Line, (800) 362-8312 |
|
Montana Medicaid/HMK Plus Member Guide |
All eligible Montana Medicaid/HMK Plus members are sent a postcard informing them how to find the Member Guide online or how to request a paper copy. This guide, which includes a section on the Passport program, is an excellent resource for members enrolled in Montana Medicaid/HMK Plus. | Call the Montana Healthcare Programs Member Services Help Line (800) 362-8312 to request a copy of the Member Guide or go to DPHHS Member Services Website. |
| Preventive Materials | Preventive healthcare letters are mailed yearly to youth with HMK Plus just before their birthday. The mailing includes an immunization and well-child exam schedule. The schedule is also available on our website. | DPHHS Well Child Website |
DPHHS requires Montana Medicaid/HMK Plus members to enroll and participate in the Passport program, unless exempt from or ineligible for participation.
Members Ineligible for Passport
DPHHS has determined the following categories of members are not eligible to participate in the Passport program:
Members Exempt from Passport
DPHHS has determined members who are eligible to participate in the Passport program may request an exempt status for the following reasons:
DPHHS has the discretion to determine hardship and to place time limits on all exemptions on a case-by-case basis. Members who are exempt from participation may elect to re-enroll in the Passport to Health program at a later time.
Passport referral is needed for most medically necessary services that the member’s Passport provider does not provide. Referrals can be made to any other provider who accepts Montana Medicaid/HMK Plus. Referrals can be verbal or written, and must be accompanied by the provider’s Passport referral number. Providers are required to keep a paper or electronic log of all Passport referrals given or received in the member’s records, a spreadsheet, or other record. The Passport provider establishes the parameters of referrals, which may be for a one-time visit, a time specific period, or the duration of a condition. An optional referral form is available on the Provider Information website.
If a provider sees a member for a routine visit or sees the member frequently and is not that member’s Passport provider, the provider should talk to the member about the importance of having a medical home. Additionally, providers should also talk to Team Care members about the importance of using the same pharmacy for prescriptions. Also discuss the importance of receiving the right care at the right time at the right place. Members need to receive regular care and not use emergency care when not absolutely necessary.
It is acceptable to deny service if the member is able to see their Passport provider. Conversely, the Passport provider is under no obligation to provide a referral if the member is able to see them. Suggest to the member that they see their Passport provider every time they are sick or hurt. It is also acceptable to suggest that the member changes to your clinic as their Passport provider. To change their provider, the member can call the Montana Healthcare Programs Member Help Line from your office or have the provider fax a Passport Provider Change Form (available on the Passport page of the Provider Information Website) signed by the member.
Providers should obtain a Passport referral in advance, and specific to services and dates. If a provider accepts a member as a Montana Medicaid/HMK Plus member and provides a service requiring a Passport referral without the member’s Passport provider’s referral, Montana Medicaid/HMK Plus will deny the claim. When a provider bills Montana Medicaid/HMK Plus for services rendered to a member, the provider has accepted the member as a Montana Medicaid/HMK Plus member and cannot bill the member for services. If a provider tried unsuccessfully to get approval from the PCP, the provider cannot bill the member unless the member agreed to pay privately before services were rendered. (ARM 37.85.406)
Passport referrals and prior authorization are different. For more information, see the Additional Passport Information chapter in this manual and Prior Authorization chapters in your provider type manual and the General Information for Providers Manual.
Establishing care with a provider helps ensure Montana Medicaid/HMK Plus members receive effective, quality medical care. The Passport program recommends that in most cases, Passport referrals should not be given to specialists or other PCPs if the member has not established care with their PCP. In most cases, care should start with and be coordinated by the Passport PCP. Encourage the member to establish a relationship with their PCP for services.
If a provider consistently receives requests for referrals for a member that the provider has never seen, it is acceptable for the provider to disenroll the member from their Passport caseload. It is also acceptable to disenroll established members who are consistently seeking primary care elsewhere or specialty care that requires provider referral. See the Disenrolling Passport or Team Care Members chapter in this manual for more details.
There are some instances where the Passport program requests that the Passport PCP provide a referral, even when care has not been established. The member’s access to care, whether or not the member has established care, is a responsibility of the member’s PCP.
A referral determination should be based on whether it is reasonable for the PCP to provide, and the member to access care in a specific situation. Some examples in which referrals are needed in order to ensure access to needed care are:
Important note: This is not an all inclusive list.
Members must obtain services directly from or through a Passport referral, except for:
The Indian Health Service (IHS) is the health care system for federally recognized American Indian and Alaska Natives (AI/AN). When AI/AN are eligible for Montana Medicaid/HMK Plus, it will pay for services provided through an IHS as well as other Montana Medicaid/HMK Plus providers. An AI/AN Montana Medicaid/HMK Plus member who is enrolled in Passport to Health may choose an IHS to be the primary care provider if the IHS is a Passport provider. The member may alternatively choose a Passport provider other than an IHS. If the member chooses a Passport provider other than an IHS, they may go to an IHS as well without a referral from the Passport provider.
Passport and Team Care referrals for a Medicaid member designated AI/AN in the Medicaid system are not required when the member is visiting an Indian Health Service Unit, Tribal 638 Facility, or Urban Indian Health Center (I/T/U).
Passport and Team Care referral is not required when an I/T/U refers an AI/AN member to a provider who is not their designated Passport provider or Team Care provider. The non-I/T/U provider will be required to have the I/T/U’s NPI present in field 17a on a CMS-1500 or field 7 on a UB-04 or claims will be denied.
EPSDT is a benefit package for all HMK Plus members designed to ensure that children receive comprehensive healthcare. The provider is encouraged to actively screen for specific pediatric problems, order diagnostic tests as indicated, and treat problems found, or if necessary, refer members to other providers for treatment.
All children should have regular well-child checkups beginning at birth and through age 20. The Passport program sends reminders to Passport members advising them that they are due for a well-child checkup.
The Passport program encourages providers to conduct well-child checkups according to a specific schedule.
Montana Healthcare Programs has adopted the Bright Futures/American Academy of Pediatrics periodicity schedule. The national schedule can be found at brightfutures.aap.org. In addition to these scheduled visits, well-child screenings should be incorporated into every visit if possible.
Well-child checkups include the following:
If a screening indicates the need for further diagnostic testing or treatment, those services should be provided without delay. If the service cannot be provided by the Passport provider, a referral must be made.
Montana Medicaid/HMK Plus covers all services that are determined to be medically necessary to members under age 21, even if those services are not covered for adults. Examples of additional services for pediatric members include chiropractic treatment, nutrition, private duty nursing, residential treatment, respiratory therapy, school-based services, and substance use disorder inpatient and day treatment.
Reimbursement for Passport member services are the same as Montana Medicaid/HMK Plus fee-for-service reimbursement. This allows providers the opportunity to become actively involved in cost containment and quality of care without financial risk. For more information on reimbursement, see your provider type fee schedule available on the Provider Information website.
In addition to fee-for-service reimbursement, Passport providers receive a monthly case management fee as defined below:
| Passport | $1 for regular Passport members $3 for aged, blind, and disabled members |
|---|---|
| Team Care | $6 for member's enrolled with the basic Passport providers |
| PCMH | Tier 1: $3.33 Tier 2: $9.33 Tier 3: $15.33 Tier 4: $470.10 (CCM Tier) Note: PCMH providers are reimbursed for Team Care members based on the member's assigned tier. |
| CPC+ Track 1 | Tier 1: $3.33 Tier 2: $9.33 Tier 3: $15.33 Tier 4: $21.33 Note: CPC+ providers are reimbursed for Team Care members based on the member's assigned tier. |
| CPC+ Track 2 | Tier 1: $6.33 Tier 2: $12.33 Tier 3: $18.33 Tier 4: $24.33 Tier 5: $34.33 Note: CPC+ providers are reimbursed for Team Care members based on the member's assigned tier. |
This PMPM fee is in a separate payment from the fee-for-service reimbursement and is paid regardless of whether the member is seen during the month. The monthly case management fee is paid with the expectation that the items listed in the provider requirements of this manual are completed as needed for member’s coordination of care. The monthly case management fee is paid to providers by their Passport number.
The fees are listed with the appropriate procedure code for each PCCM enrollee on the provider’s remittance advice. The date of service for the code is shown as the first of the month for which the fee is being paid. Each Passport companion program has their own procedure codes provided below:
| PCCM Program | Procedure Code |
|---|---|
| Passport | G9008 |
| Team Care | G9008 |
| PCMH | G9012 |
| CPC+ Track 1 and Track 2 | G9005 |
| T-HIP | T2022 |
Verify member's eligibility and Passport provider at each visit before treating the member. Contact Provider Relations for information on Montana Medicaid/HMK Plus claims.
Do not bill for case management fees; they are paid automatically to the provider each month. Team Care is a component of the Passport program; therefore, Team Care billing procedures are the same as Passport. Link your Passport to your submitter number to ensure that case management fee appear on your remittance advices.
For additional instructions on billing Montana Medicaid/HMK Plus, refer to your provider type manual.
The Passport referral number is the number the PCP gives to providers when approving services. This is a number issued to the Passport provider and must be on the requesting provider’s claim or Montana Medicaid/HMK Plus will deny the service if it requires a Passport referral.
The Passport referral number is recorded in Box 17a on a CMS-1500 claim and Box 7 on a UB-04 claim. The referring provider’s NPI is not required.
Passport and Team Care referral is not required when an I/T/U refers an American Indian/Alaska Native (AI/AN) member to a provider who is not their designated Passport provider or Team Care provider. The non-I/T/U provider will be required to have the I/T/U’s NPI present in field 17a on a CMS-1500 or field 7 on a UB-04 or claims will be denied.
To bill a Montana Medicaid/HMK Plus member, an agreement must be signed by the member in advance of services. There are two types of member agreements:
Providers may not bill a member when the provider has informed the member that Montana Medicaid/HMK Plus may not pay or when the agreement is contained in a form that provider routinely requires members to sign. Members may be billed for:
Providers are required to accept the amount paid by Montana Medicaid/HMK Plus as payment in full. Unless an agreement is signed, members may not be billed for:
When a member is accepted as a Montana Medicaid/HMK Plus member in a service setting (e.g., facility, institution), all other providers performing services for the member will be deemed to have accepted the member as a Montana Medicaid/HMK Plus member.
Acceptance of a member as a Montana Medicaid/HMK Plus member applies to all services provided by the provider. A provider may not accept Montana Medicaid/HMK Plus for some covered services but refuse Montana Medicaid/HMK Plus for other covered services.
If a member has agreed prior to services that payment will be made from a source other than Montana Medicaid/HMK Plus but is later determined retroactively eligible for Montana Medicaid/HMK Plus, the provider may choose to accept the individual as Montana Medicaid/HMK Plus or seek payment in accordance with the original payment agreement.
A provider who bills Montana Medicaid/HMK Plus for services will be deemed to have accepted the member as Montana Medicaid/HMK Plus.
Bills owed to a provider do not affect the Passport relationship. A member may not be denied services or be disenrolled by the Passport provider due to unpaid bills. (ARM 37.86.402)
A provider may disenroll a Passport or Team Care member for the following reasons:
A provider cannot disenroll a Passport or Team Care member for the following reasons:
A written disenrollment notification must be sent to the member and Conduent by providing 30 days' notice.
Verbal notification to the member does not constitute disenrollment; the provider remains responsible for the care of the member until the disenrollment process is complete.
Reasons for disenrollment must be explained in writing, must be non-discriminatory, must be generally applied to the provider’s entire patient base. Please use the PCCM Member Disenrollment Form on the Passport page of the Provider Information Website.
A copy of the member’s disenrollment notification must be mailed or faxed to the Conduent Passport to Health Analyst. During these 30 days, the provider must continue to treat the member or refer the member to another provider. The provider is responsible for serving the Passport member for 30 days after the submission of the disenrollment to the Conduent Passport Provider Analyst. The Passport Provider Analyst cannot make exceptions. DPHHS may allow exceptions under rare circumstances.
Providers may call the Conduent Passport Provider Analyst with questions about the disenrollment process. The Passport program will not disenroll members from a PCP without written notification from the provider. The Montana Healthcare Programs Member Help Line will assist the member in selecting a new PCP.
Formal complaints filed against a provider or healthcare facility for improper care or unsafe conditions will be forwarded to the proper state licensing agency. Informal member complaints or grievances about healthcare services rendered by a provider or professional will be forwarded to the program officer with knowledge of the program. Informal member complaints will be addressed by the program officer within 7 business days.
If a provider believes DPHHS has made a decision that fails to comply with applicable laws, regulations, rules, or policies, the provider may request an administrative review or fair hearing. Requests must be addressed to the Office of Fair Hearings. A copy must also be delivered or mailed to the division that issued the contested determination.
To request an administrative review, state in writing the objections to the decision made by DPHHS and include substantiating documentation for consideration in the review.
DPHHS must receive the request within 30 days from the date the initial determination from DPHHS was mailed. Providers may request extensions in writing within these 30 days. If the provider is not satisfied with the DPHHS administrative review results, a fair hearing may be requested. Fair hearing requests must contain concise reasons the provider believes the DPHHS administrative review determination fails to comply with applicable laws, regulations, rules, or policies. This document must be signed and received by the Office of Fair Hearings within 30 days from the date DPHHS mailed the administrative review determination.
Providers shall not discriminate illegally in the provision of service to eligible Medicaid recipients or in employment of persons on the grounds of race, creed, religion, color, sex, national origin, political ideas, marital status, age, or disability.
Discrimination may not occur regarding admission to, participation in, or receipt of services or benefits of any of its programs, activities, or employment, whether carried out by DPHHS or through a contractor or other entity. In case of questions or in the event that you wish to file a complaint alleging violations, contact DPHHS, Office of Human Resources.
If you wish to file a complaint with the Office of Civil Rights, contact them at the address or telephone number on the Contact Us page of the Provider Information website. A person does not have to go through the administrative review or fair hearing process to file a complaint with the Office for Civil Rights.
The Passport forms listed below are found on the Passport page (mt.gov) and others are available on the Forms page (mt.gov) of the Provider Information website.
The forms listed below are found on the Forms or Passport to Health pages of the Montana Healthcare Programs Provider Information website.
Passport to Health- https://medicaidprovider.mt.gov/passport
This section contains definitions and acronyms specific to Passport provider. Additional definitions and acronyms are found on the Definitions and Acronyms page of the Provider Information website.
A group Passport provider is enrolled in the program as having one or more Montana Medicaid/HMK Plus providers practicing under one Passport number.
A solo Passport provider is enrolled in the program as an individual provider with one Passport number.
A well-child checkup is an important way to monitor growth and development of young members. Regular checkups provide an opportunity for providers to develop a strong relationship with their members.
This edition has three search options.
1. Search the whole manual. Open the Complete Manual pane. From your keyboard press the Ctrl and F keys at the same time. A search box will appear. Type in a descriptive or key word (for example "Denials"). The search box will show all locations where denials are discussed in the manual.
2. Search by Chapter. Open any Chapter tab (for example the "Billing Procedures" tab). From your keyboard press the Ctrl and F keys at the same time. A search box will appear. Type in a descriptive or key word (for example "Denials"). The search box will show where denials are discussed in just that chapter.
3. Site Search. Search the manual as well as other documents related to a particular search term on the Montana Healthcare Programs Site Specific Search page.