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 07/26/2021
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 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 Prescription Drug Program Manuals. Published by the Montana Department of Public Health & Human Services, July 2001.
Updated October 2001, December 2001, May 2002, June 2002, September 2002, January 2003, August 2003, July 2004, November 2004, May 2011, August 2011, October 2011, December 2011, January 2013, March 2013, July 2013, September 2013, March 2015, June 2015, January 2016, July 2016, October 2016, December 2016, August 2017, February 2018, July 2018, November 2018, July 2019, January 2020, July 2020, April 2021, October 2021, and July 2022.
CPT codes, descriptions and other data only are copyright 2014 American Medical Association (or such other date of publication of CPT). All Rights reserved. Applicable FARS/DFARS Apply.
07/21/2022
10/26/2021
Updated Montana Healthcare Programs Covered Products and Reimbursement chapters.
04/13/2021
Added the COVID-19 vaccine administration rates to the Reimbursement chapter.
07/01/2020
Updated dispensing fees and the vaccine administration fee.
01/01/2020
07/08/2019
References to the MA-5 were replaced with references to the Universal Claim Form Version 1.2-02/2013 throughout the manual. Instructions for the Universal Claim Form replaced instructions for the MA-5 form. Seasonale® removed from the 34-day supply exception list. Vasopressors-midodrine removed from the drug classes considered for maintenance medications list.
11/27/2018
Reimbursement Chapter was updated with current rates.
07/31/2018
How to Bill Pharmacy Claims was added to the Billing Procedures chapter and obsolete language was removed from the Drug Program chapter.
07/10/2018
Dispensing Limitations was updated.
02/9/2018
Reimbursement rates were updated in the Reimbursement chapter.
09/26/2017
A portion of the Federal Maximum Allowable Cost section in the Reimbursement chapter was eliminated.
08/08/2017
Mental Health Services - Adult Manual converted to an HTML format and adapted to 508 Accessibility Standards.
06/15/2016
Prescription Drug Program, July 2016: Cost Share Updates
12/31/2015
Prescription Drug Program, January 2016: HELP Plan-Related Updates and Others
07/21/2015
Prescription Drug Program, Prior Authorization, Reimbursement, and Billing Procedures
03/25/2015
Prescription Drug Program, Entire Manual
09/27/2013
Prescription Drug Program, Reimbursement
09/05/2013
Prescription Drug Program, Entire Manual Including the New Passport Chapter. This set of replacement pages contains a terminology change ("client" to "member"); however, only content changes are marked with a change bar (black line).
04/17/2013
Prescription Drug Program, Key Contacts and Reimbursement
02/04/2013
Prescription Drug Program, Medicaid Covered Products
02/01/2012
Prescription Drug Program, Multiple Chapters
09/01/2011
Prescription Drug Program, Medicaid Covered Services and Reimbursement (Dispensing Fee) and MHSP Covered Products (Formulary Drugs)
06/17/2011
Prescription Drug Program; Entire manual has changed from last posted version.
11/16/2004
Prescription Drug Program, Updated Prescription Drug Prior Authorization Criteria
06/16/2004
Prescription Drug Program, Prior Authorization and HIPAA Updates
06/10/2004
Prior Authorization Additions
For all questions regarding drug prior authorization:
(800) 395-7961
(406) 443-6002 (Helena)
8 a.m. to 5 p.m., Monday–Friday
Mountain Time
Mail or fax backup documentation to:
Mountain-Pacific Quality Health
P.O. Box 5119
Helena, MT 59604
(800) 294-1350 Fax
(406) 513-1928 Fax Helena
For assistance with online POS claims adjudication:
Conduent, Atlanta
Technical POS Help Desk
(800) 365-4944
6 a.m. to midnight, Monday–Saturday;
10 a.m. to 9 p.m., Sunday
Eastern Time
For program policy questions:
(406) 444-2738 Phone
(406) 444-1861 Fax
Allied Health Services Bureau
1400 Broadway
P.O. Box 202951
Helena, MT 59620
Thank you for your willingness to serve members of the Montana Healthcare Programs administered by the Department of Public Health and Human Services.
This manual provides information specifically for Prescription Drug Program providers. Other essential information for providers is contained in the separate General Information for Providers Manual. Providers are responsible for reviewing both manuals.
Notification of manual updates are provided through the weekly web postings under “Recent Website Posts” on the Home page of the Provider website. Older versions of the manual may be found through the Archive page on the Provider Information website. 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 make sure that the policy they are researching or applying has the correct effective date for their circumstances.
Providers must be familiar with all current rules and regulations governing the Montana Healthcare Programs. Provider manuals are to assist providers in billing Montana Healthcare Programs; they do not contain all Montana Healthcare Programs rules and regulations. Rule citations in the text are a reference tool; they are not a summary of the entire rule. If a manual conflicts with a rule, the rule prevails. Links to rules are available on the Provider Information website. Paper copies of rules are available through the Secretary of State’s office. In addition to the general Montana Healthcare Programs rules outlined in the General Information for Providers Manual, the following rules and regulations are also applicable to the Prescription Drug Program:
The Department is committed to paying Montana Healthcare Programs providers’ claims as quickly as possible. Montana Healthcare Programs claims are electronically processed and usually are not reviewed by medical experts prior to payment to determine if the services provided were appropriately billed. Although the computerized system can detect and deny some erroneous claims, there are many erroneous claims which it cannot detect. For this reason, payment of a claim does not mean that the service was correctly billed, or the payment made to the provider was correct. Periodic retrospective reviews are performed which may lead to the discovery of incorrect billing or incorrect payment. If a claim is paid and the Department later discovers that the service was incorrectly billed or paid or the claim was erroneous in some other way, the Department is required by federal regulation to recover any overpayment, regardless of whether the incorrect payment was the result of Department or provider error or other cause.
The provider manuals are designed to answer most questions; however, questions may arise that require a call to a specific group (such as a program officer, Provider Relations, or a prior authorization unit). The Key Contacts chapter and the Contact Us link on the Provider Information website have important phone numbers and addresses. Montana Healthcare Programs manuals, provider notices, fee schedules, forms, and more are available on the Provider Information website.
The Prescription Drug Program covers pharmaceuticals and pharmacist services to members served by the Department in the Montana Healthcare Programs and the Mental Health Services Plan (MHSP).
Primary authority for the prescribing of legend drugs and controlled substances comes from individual professional practice acts, usually in the section of the act which defines the scope of practice for the profession. The definition of scope of practice is the responsibility of the board that licenses the professional. Only those providers not excluded by federal programs are eligible.
The Drug Use Review (DUR) Board performs drug utilization review and educational interventions. Five pharmacists and four physicians comprise the DUR Board which is coordinated by a full-time registered Montana pharmacist. The DUR Board meets monthly to review utilization and advise the Department.
Drug Use Review (DUR) Board meetings are posted on the Provider website. On the Pharmacy page, click on the Drug Use Review (DUR) Board pane.
The DUR Board and The University of Montana Skaggs School of Pharmacy also advise the Department on its outpatient drug formulary. Drugs are evaluated for safety, effectiveness, and clinical outcome. Drugs recommended for formulary exclusion have no significant, clinically meaningful therapeutic advantage over drugs recommended for inclusion.
Drug coverage is limited to those products where the pharmaceutical manufacturer has signed a rebate agreement with the federal government. Federal regulations further allow states to impose restrictions on payment of prescription drugs through prior authorization and preferred drug lists (PDL).
The Montana Healthcare Programs Prescription Drug Program covers the following:
The Montana Healthcare Programs Prescription Drug Program does not reimburse for the following items or services:
To address the rising costs of prescription drugs, Montana Healthcare Programs implemented a preferred drug list (PDL) in 2005. The Department of Public Health and Human Services uses this program to provide clinically effective and safe drugs to its members at the best available price.
The PDL addresses certain classes of medications and provides a selection of therapeutically effective products for which the Montana Healthcare Programs will allow payment without restriction in those targeted classes. The Department, through its Formulary Committee, designates this listing of preferred drugs as “preferred” based primarily on clinical efficacy. In the designated classes, drug products that are non-preferred on the PDL will require prior authorization.
The Department updates the PDL annually and periodically as new drugs and information become available.
The current Montana PDL can be found on the Preferred Drug Information tab on the Pharmacy Page of the Provider Information website. Providers may address questions regarding the PDL and requests for prior authorization to the Drug Prior Authorization Unit. (See the Key Contacts chapter) The PDL/Prior Authorization Help Line is for providers only. Montana Healthcare Programs members with questions can ask their providers or call the Member Help Line, (800) 362-8312.
Part D
Medicare added prescription drug coverage for its beneficiaries under the Medicare Modernization Act, 42 USC 1302 Sec. 1395. Members enrolled in Medicare Part A and/or Part B are eligible for Medicare Part D and are required to receive their drug benefits through a Medicare Prescription Drug Plan (PDP). Members enrolled in both Montana Healthcare Programs and Medicare are considered “dual eligible” and are auto-enrolled in a Medicare PDP if they do not choose a plan. The Montana Healthcare Programs reimbursement for outpatient drugs provided to a full-benefit dual eligible member will be limited to the excluded drugs identified in this chapter and the Part B drugs described in the following paragraph.
Part B
Claims cross over automatically if the provider’s NPI/API is on file with Montana Healthcare Programs. The taxonomy code for the pharmacy is required on the claim.
To bill paper claims:
Montana Healthcare Programs allowed for the pharmacy supplying and dispensing fee is $4.94.
For an updated list of covered Part B drugs, visit the CMS website, https://www.cms.gov.
The MHSP formulary includes the following types of drugs:
Refer to the MHSP formulary on the Pharmacy page of the Provider Information website.
Medications may not be dispensed in quantities greater than a 34-day supply except where manufacturer packing cannot be reduced to a smaller quantity.
1. The following drug classes are considered maintenance medications and may be dispensed up to a 90-day supply.
Cardiovascular (Heart Health)
Diabetes
Central Nervous System
Gastrointestinal
Renal System
Respiratory
Men and Women’s Health
Other Body Systems
2. No more than two prescriptions of the same drug may be dispensed in a calendar month except for the following:
The DUR Board has set monthly limits on certain drugs. Use over these amounts requires prior authorization.
Prescriptions for non-controlled substances may be refilled after 75% of the estimated therapy days have elapsed. Prescriptions for controlled substances (CII-CV), Ultram (tramadol), Ultracet (tramadol/acetaminophen), carisoprodol, and gabapentin may be refilled after 90% of the estimated therapy days have elapsed. The POS system will deny a claim for “refill to soon” based on prescriptions dispensed on month-to-month usage.
A prescription may be refilled early only if the prescriber changes the dosage, or if the member was admitted to a nursing facility. The pharmacist must document any dosage change. In any circumstance, the provider must contact the Drug Prior Authorization Unit to receive approval. (See Key Contacts.)
Pharmacists who identify members who experience difficulties in managing their drug therapy may consider unit dose prescriptions (see below).
The Department has a mandatory generic edit in the claims processing system. The edit is enabled once there are two rebateable AB-rated generic drugs available in the marketplace. Typically, the first generic labeler will have a six-month period of market exclusivity. To maximize value to the State, the Department recommends dispensing the brand name drug over the generic during this period of market exclusivity. Brands may be preferred over generics in other instances where there is a net cost benefit to the Department. Brand over generic preferences are listed on the PDL. When there are “preferred brands” on the Department’s PDL, generic equivalent drugs will require a prior authorization.
For drugs not subject to PDL restrictions and for those drugs listed in the Dispense As Written (DAW) section of the Billing Procedures chapter, if the brand name drug is prescribed instead of a generic equivalent, the prescriber must get prior authorization.
Authorization is based on medical need such as adverse reactions or therapeutic failures (clinically demonstrated, observed and documented) which have occurred when the generic drug has been used.
Pharmacy-packaged unit dose medications may be used to supply drugs to members in nursing facilities, group homes, and other institutional settings.
Members who are not in one of the above facilities may also be considered high-risk and eligible for unit dose packaging if they:
Unit dose prescriptions may not exceed the 34-day supply limit.
The Department shall reimburse pharmacies for compounding drugs only if the member’s drug therapy needs cannot be met by commercially available dosage strengths and/or forms of the therapy.
Prescription claims for compound drugs shall be billed and reimbursed using the National Drug Code (NDC) number and quantity for each compensable ingredient in the compound. No more than 25 ingredients may be reimbursed in any compound. Reimbursement for each drug component shall be determined in accordance with ARM 37.86.1101. Prior authorization requirements for individual components of a compound must be met for reimbursement purposes. The Department does not consider reconstitution to be compounding.
The Department may reimburse for compounded non-rebateable API bulk powders and excipients on the Department’s drug formulary maintained in accordance with ARM 37.86.1102.
Many drug products require prior authorization before the pharmacist provides them to the member. Requests are reviewed for medical necessity.
Drug Prior Authorization Unit
Mountain-Pacific Quality Health
P.O. Box 5119
Helena, MT 59604
(406) 443-6002 or 800-395-7961 (Phone)
(406) 513-1928 or 800-294-1350 (Fax)
All prior authorization requirements must be met for retroactively eligible members.
When a member is determined retroactively eligible for Montana Healthcare Programs, the member should give the provider a Notice of Retroactive Eligibility (160-M).
The provider has 12 months from the date retroactive eligibility was determined to bill for those services.
Retroactive Montana Healthcare Programs eligibility does not allow a provider to bypass prior authorization requirements.
When a member becomes retroactively eligible for Montana Healthcare Programs, the provider may:
Providers may choose whether to accept retroactive eligibility. (See the General Information for Providers Manual, Member Eligibility and Responsibilities chapter.) All prior authorization requirements must be met to receive Montana Healthcare Programs payment.
When submitting claims for retroactively eligible members, attach a copy of the Notice of Retroactive Eligibility (Form 160-M) to the claim if the date of service is more than 12 months earlier than the date the claim is submitted.
For a list of drugs requiring prior authorization, contact the Drug Prior Authorization Unit. (See Key Contacts.)
Reimbursement for covered brand and generic preferred drugs shall not exceed the lowest of:
Average Acquisition Cost
Average acquisition cost (AAC) is the calculated average drug ingredient cost per drug determined by direct pharmacy survey, wholesale survey, and other relevant cost information. The AAC rates are published online under the Pharmacy Provider webpage.
Submitted Ingredient Cost
Submitted Ingredient is a pharmacy’s actual ingredient cost. For drugs purchased under the 340B Drug Pricing Program, submitted ingredient cost means the actual 340B purchase price. For drugs purchased under the Federal Supply Schedule (FSS), submitted ingredient cost means the actual FSS purchase price.
The usual and customary charge is the price the provider most frequently charges the general public for the same drug. In determining “usual and customary” prices, the Department:
Federal Maximum Allowable Cost (MAC)
Dispensing Fee
Pharmacies can receive a vaccine administration fee. This fee is in lieu of the standard dispensing fee. The fee for the first vaccine administered will be $21.32; the fee for each additional vaccine administered will be $15.65.
For the COVID-19 vaccine, Montana Healthcare Programs will follow the Medicare established rates for the administration fee, which are different from the above rates.
The remittance advice is the best tool providers have to determine the status of a claim. Remittance advices accompany payment for services rendered. The remittance advice provides details of all transactions that have occurred during the previous remittance advice cycle. Each line of the remittance advice represents all or part of a claim and explains whether the claim or service has been paid, denied, or suspended (also referred to as pending). If the claim was suspended or denied, the remittance advice also shows the reason. See the General Information for Providers manual for more information on the remittance advice.
As of July 2013, all new providers were required to enroll in electronic funds transfer (EFT) and receive electronic remittance advices. Providers who enrolled prior to July 2013 who received paper checks or paper remittance advices were transitioned to the electronic-only system over time.
Credit balances occur when claim adjustments reduce original payments causing the provider to owe money to the Department. These claims are considered in process and continue to appear on the remittance advice until the credit has been satisfied. Credit balances can be resolved in two ways:
Rebillings and adjustments are important steps in correcting any billing problems you may experience. Knowing when to use the rebilling process versus the adjustment process is important. When submitting a reversal (void) use a B2 NCPDP transaction and when submitting a rebilled claim or an adjustment use a B3 NCPDP transaction (void & rebill).
Timeframe for Rebilling or Adjusting a Claim
Rebilling Montana Healthcare Programs
Rebilling is when a provider submits a claim or claim line to Montana Healthcare Programs that was previously submitted for payment but was either returned or denied. Pharmacy providers can rebill Montana Healthcare Programs via point-of-sale or on paper. Paper claims are often returned to providers before processing because information such as the NPI or authorized signature/date are missing or unreadable. See the Billing Procedures chapter for tips on preventing returned or denied claims.
When to Rebill Montana Healthcare Programs
How to Rebill
Adjustments
If a provider believes that a claim has been paid incorrectly, the provider may call Provider Relations. Once an incorrect payment has been verified, the provider may submit an Individual Adjustment Request form to Provider Relations or submit an adjustment through point-of-sale. If incorrect payment was the result of a Conduent keying error, the provider should contact Provider Relations.
When adjustments are made to previously paid claims, the Department recovers the original payment and issues appropriate repayment. The result of the adjustment appears on the provider’s RA as two transactions. The original payment will appear as a credit transaction. The replacement claim reflecting the corrections will be listed as a separate transaction and may or may not appear on the same remittance advice as the credit transaction. The replacement transaction will have nearly the same ICN number as the credit transaction, except the 12th digit will be a 2, indicating an adjustment. Adjustments are processed in the same time frame as claims.
When to Request an Adjustment
How to Request an Adjustment
To request an adjustment, use the Individual Adjustment Request form. Adjustments may also be made using point-of-sale. The requirements for adjusting a claim are as follows:
Completing an Adjustment Request Form
Section A
Field: 1. Provider Name and Address
Description: Provider’s name and address (and mailing address if different).
Field: 2. Member Name
Description: The member’s name.
Field: 3.* Internal Control Number (ICN)
Description: There can be only one TCN per Adjustment Request form. When adjusting a claim that has been previously adjusted, use the TCN of the most recent claim.
Field: 4*. Provider NPI/API
Description: The provider’s NPI/API
Field: 5*. Member's Montana Healthcare Programs Number
Description: Member's Montana Healthcare Programs ID number.
Field: 6. Date of Payment
Description: Date claim was paid found on Remittance Advice Field 5 (see the sample RA earlier in this chapter).
Field: 7. Amount of Payment
Description: The amount of payment from the Remittance Advice Field 19 (see the sample RA earlier in this chapter.).
Section B
Field: 1. Units of Service
Description: If a payment error was caused by an incorrect number of units, complete this line.
Field: 2. Procedure Code/NDC/Revenue Code
Description: If the procedure code, NDC, or revenue code are incorrect, complete this line.
Field: 3. Dates of Service (DOS)
Description: If the date of service is incorrect, complete this line.
Field: 4. Billed Amount
Description: If the billed amount is incorrect, complete this line.
Field: 5. Personal Resource (Nursing Facility)
Description: If the member's personal resource amount is incorrect, complete this line.
Field: 6. Insurance Credit Amount
Description: If the member’s insurance credit amount is incorrect, complete this line.
Field: 7. Net (Billed - TPL or Medicare Paid)
Description: If the payment error was caused by a missing or incorrect insurance credit, complete this line. Net is billed amount minus the amount TPL or Medicare paid.
Field: 8. Other/Remarks
Description: If none of the above items apply, or if you are unsure what caused the payment error, complete this line.
*Indicates a required field
Mass Adjustments
Mass adjustments are done when it is necessary to reprocess multiple claims. They generally occur when:
Providers receive their Montana Healthcare Programs payment and remittance advices weekly. To sign up for EFT (direct deposit) and register for the web portal to view or download remittance advices, providers need to complete the EFT and ERA Authorization Agreement and the EDI Trading Partner Agreement and mail or fax them to Provider Relations. See the Provider Enrollment page for those documents.
A letter from your financial institution verifying legitimacy of the account is also required. The letter must include the name and contact information of the bank representative and be signed by the bank representative. Do not send voided checks or deposit slips.
Once enrolled in EFT and registered for the MATH web portal, providers are able to receive their electronic remittance advices. Due to space limitations, each remittance advice is available on the web portal for 90 days.
For assistance on enrolling in EFT, completing the EDI Trading Partner Agreement, and registering for the MATH web portal, contact Provider Relations.
Provider Enrollment
P.O. Box 4936
Helena, MT 59604
(800) 624-3958
(406) 442-1837
Written prescriptions must contain all of the following.
Outpatient pharmacy claims for Montana Healthcare Programs and MHSP require the prescription origin code to indicate the source of the prescription. Valid values for prescription origin code are:
Providers are required to submit a clean claim no later than 365 days from:
A clean claim is one that can be adjudicated without correction or additional information or documentation from the provider.
Prescription Tracking and Claim Reversals
For purposes of billing for prescribed drugs, the date of service means the date a prescription is filled. If the drug has not been received by the member or the member’s representative within 15 days after the prescription is filled, the pharmacy must reverse the claim and refund the payment to the Department.
Tips to Avoid Timely Billing Denials
In most circumstances, providers may not bill Montana Healthcare Programs members for services covered under Montana Healthcare Programs. More specifically, providers cannot bill members directly:
Under certain circumstances, providers may need a signed agreement in order to bill a Montana Healthcare Programs member (see the following table).
Routine Agreement: This may be a routine agreement between the provider and member which states that the member is not accepted as a Montana Healthcare Programs member, and that he/she must pay for the services received.
Custom Agreement: This agreement lists the service the member will receive and states that the service is not covered by Montana Healthcare Programs and that the member will pay for the services received.
When the provider accepts the member’s retroactive eligibility, the provider has 12-months from the date retroactive eligibility was determined to bill for those services.
When submitting claims for retroactively eligible members in which the date of service is more than 12 months earlier than the date the claim is submitted, attach a copy of the Provider Notice of Eligibility (Form 160-M). The provider must request the form from the member’s local Office of Public Assistance.
See https://dphhs.mt.gov/hcsd/OfficeofPublicAssistance. For more information on retroactive eligibility, see the Member Eligibility and Responsibilities chapter in the General Information for Providers Manual.
Providers should bill Montana Healthcare Programs their usual and customary charge for each service; that is, the same charge that is made to other payers for that service.
Effective for all claims paid on or after January 1, 2020 co-payment will not be assessed. For members with Mental Health Services Plan (MHSP) coverage, there is a $425 pharmacy cap. The MHSP program pays for the first $425 in prescriptions for the member each month, and the member must pay privately for any amounts over that cap.
The provider must always use the complete 11-digit NDC from the dispensing container.
All outpatient prescription drugs are billed using the drug’s NDC, the 11-digit code assigned to all prescription drug products by the labeler or distributor of the product under FDA regulations.
The Department accepts only the 5-4-2 NDC format. All 11 digits, including zeros, must be entered. The three segments of the NDC are:
SAMPLE NDC: 12345-6789-10
12345 = labeler code
6789 = product code
10 = package size
Claims must accurately report the NDC dispensed, the number of units dispensed, days supply, and the date of dispensing. Use of an incorrect NDC or inaccurate reporting of a drug quantity will cause the Department to report false data to drug manufacturers billed for drug rebates.
The Department will recover payments made on erroneous claims discovered during dispute resolution with drug manufacturers. Pharmacies are required to document purchase for quantities of brands of drugs reimbursed by the Department if disputes occur.
Prescribers and pharmacies must prescribe and dispense the generic form of a drug whenever possible. Except for those drugs listed below, prior authorization is required when a brand name drug is prescribed instead of a generic equivalent. Please use the following DAW codes for these situations:
The following practices constitute abuse and misutilization:
Montana Healthcare Programs will not approve a claim with a negative payment amount (from click fees or PBM clawbacks) or allow pharmacies to bypass the primary insurance to eliminate the negative payment amount. If a pharmacy receives a negative amount from the primary insurance and a member has Montana Healthcare Programs as secondary, the pharmacy must bill with the following to receive payment from the Department:
In addition, providers are reminded that aside from a member copayment, if there is one, payment from Montana Healthcare Programs is payment in full. Negative payment amounts may not be passed on to members.
Pharmacies who fill medications for PRTFs are able to bill for non-psychotropic medications for members currently in an all-inclusive PRTF by submitting the claim with a submission clarification code (SCC) of 10 in NCPDP field (420-DK). If these pharmacies receive a claim rejection of “member enrolled in all-inclusive program, contact facility for payment” despite submitting with a SCC code of 10, this indicates the medication being billed is classified as a psychotropic medication and can’t be reimburse through the pharmacy benefit. Psychotropic medications are included in the all-inclusive payment and must be billed to the facility. However, if the medication is on the psychotropic list but is being used for a non-psychiatric diagnosis, a prior authorization may be obtained by calling the Drug Prior Authorization Unit at (406) 443-6002 or (800) 395-7961.
If pharmacies are trying to bill prescriptions for a member that has been released from an all-inclusive facility but are still getting denied claims with the same rejection referenced above, please contact the Pharmacy Program Officer or the Montana Healthcare Programs Pharmacist.
The point-of-sale (POS) system finalizes claims at the point of entry as either paid or denied. Pharmacies arrange their own telecommunications switch services to accept Montana Healthcare Programs point of sale and are responsible for any charges imposed by these vendors. Hard copy (paper) billing is still accepted when billed on a Universal Claim Form Version 1.2-02/2013. All claims are processed and edited through the POS system regardless of how the claim was originally submitted.
If the claim continues to deny for eligibility past 3 working days, call Provider Relations at (800) 624-3958.
Possession of a Montana Access to Health (MATH) Montana Healthcare Programs ID card is not proof of eligibility.
Member eligibility may change monthly, so providers should verify eligibility each month. Both the 7-digit member number and the member’s Social Security number are billable numbers. If a claim is rejected online, a provider should verify eligibility by one of the methods (MATH web portal, IVR, FaxBack, calling Provider Relations) described in the General Information for Providers Manual.
The POS system performs all major prospective drug utilization review (Pro-DUR) edits. In some circumstances, the Pro-DUR edits result in denied claims. When a Pro-DUR denied claim needs to be overridden, pharmacy providers may enter one Reason for Service Code (formerly DUR Conflict Code) from each category in the following order, as long as the indicated situations exist and the pharmacy retains documentation in its files:
By placing codes into the claim, the provider is certifying that the indicated DUR code is true and documentation is on file. For questions regarding DUR codes, contact the Drug Prior Authorization Unit.
Providers may also request online login access from CommuniForm LLC by calling (877) 817-3676. Forms can be ordered online by logging in at https://www.asbaces.com/NEWACES/(S(exhfqdwrar3yfin0ozystqw0))/storefront.aspx.
For MHSP claims, clearly write MHSP ONLY on the face of each paper claim.
Paper claims must be mailed to the following address:
Claims Processing Unit
P.O. Box 8000
Helena, MT 59604
Field Number | Field Title | Instructions |
---|---|---|
1 | ID-Insurance | Enter the Member ID. |
2 | Group ID-Insurance | Enter the insurance Group ID. |
3 | Last-Insurance | Enter the last name of the member |
4 | First-Insurance | Enter the first name of the member. |
5 | Plan Name-Insurance | Enter the plan name for the member. |
6 | BIN #-Insurance | Enter the BIN number from the member ID Card. |
7 | Processor Control #-Insurance | Enter the PCN number from the member ID card. |
8 | CMS Part D Defined Qualified Facility | Enter a "Y" or "N" if the pharmacy is a CMS Part D Defined Qualified Facility. |
9 | Last-Member | Enter the member last name. |
10 | First-Member | Enter the member first name. |
11 | Person Code-Member | Enter the three digit person code. |
12 | D.O.B.-Member | Enter the member date of birth in MM-DD-CCYY format. |
13 | Gender-Member | Enter the member gender code. |
14 | Relationship-Member | Enter the relationship code between the member and cardholder. |
15 | Member Residence-member | Enter the member residence code. |
16 | DO NOT USE | Leave this field blank. |
17 | Service Provider ID-Pharmacy | Enter the pharmacy ID. |
18 | Qualifier-Pharmacy | Enter the service provider ID qualifier code. |
19 | Name-Pharmacy | Enter the name of the pharmacy. |
20 | Telephone #-Pharmacy | Enter the telephone number for the pharmacy. |
21 | Address-Pharmacy | Enter the address of the pharmacy. |
22 | City-Pharmacy | Enter the city of the pharmacy. |
23 | State-Pharmacy | Enter the State of the Pharmacy. |
24 | Zip-Pharmacy | Enter the zip code for the pharmacy. |
25 | Signature of Provider | The provider must sign this field. |
26 | Date | Enter the date in which the provider signed the paper claim. |
27 | ID-Prescriber | Enter the ID for the prescribing provider. |
28 | Qualifier-Prescriber | Enter the the prescriber ID qualifier. |
29 | Last Name-Prescriber | Enter the prescriber's last name. |
30 | ID-Pharmacist | Enter the pharmacist's ID number. |
31 | Qualifier-Pharmacist | Enter the pharmacist's ID qualifier. |
32 | Prescription/Service Ref. #-Claim | Enter the Prescription or reference number. |
33 | Qual-Claim | Enter the prescription or service ID qualifier. |
34 | Fill #- Claim | Enter the fill number. |
35 | Date Written-Claim | Enter the date the prescription was written. |
36 | Date of Service-Claim | Enter the date of service. |
37 | Submission Clarification-Claim | Enter the submission clarification code. |
38 | Prescription Origin-Claim | Enter the prescription origin code. |
39 | Pharmacy Service Type-Claim | Enter the pharmacy service type code. |
40 | Special Packaging Indicator-Claim | Enter the special packaging indicator code. |
41 | Product/Service ID-Claim | Enter the product/service ID. |
42 | Qual-Claim | Enter the product/service ID qualifier. |
43 | Product Description-Claim | Enter the product description. |
44 | Quantity Dispensed-Claim | Enter the quantity dispensed. |
45 | Days Supply-Claim | Enter the days supply dispensed. |
46 | DAW Code- Claim | Enter the appropriate DAW code. |
47 | Prior Auth # Submitted-Claim | Enter the prior authorization number submitted. |
48 | PA Type-Claim | Enter the prior authorization type code. |
49 | Other Coverage-Claim | Enter the appropriate other coverage code, if applicable. |
50 | Delay Reason-Claim | Enter the appropriate delay reason code. |
51 | Level of Service-Claim | Enter the level of service. |
52 | Place of Service-Claim | Enter the place of service. |
53 | Quantity Prescribed-Claim | Enter the total quantity prescribed. |
54 | Diagnosis Code-Clinical | Enter the appropriate diagnosis code. |
55 | Qual-Clinical | Enter the diagnosis code qualifier. |
56 | DUR/PPS Codes- Reason-DUR | Enter the DUR/PPS reason for service code. |
57 | DUR/PPS Codes-Service-DUR | Enter the DUR/PPS service code. |
58 | DUR/PPS Codes-Result-DUR | Enter the DUR/PPS result of service code. |
59 | Level of Effort-DUR | Enter the level of effort-required when billing a compound. |
60 | Procedure Modifier-DUR | Enter the procedure modifier. |
61 | Other Payer ID-COB 1 | Enter the other payer ID when COB is present. |
62 | Qual-COB 1 | Enter the other payer ID qualifier. |
63 | Other Payer Date-COB 1 | Enter the date in which the other payer paid the claim. |
64 | Other Payer Rejects-COB 1 | Enter the other payer reject codes (maximum of 3). |
65 | Other Payer ID-COB 2 | Enter the other payer ID when COB is present. |
66 | Qual-COB 2 | Enter the other payer ID qualifier. |
67 | Other Payer Date-COB 2 | Enter the date in which the other payer paid the claim. |
68 | Other Payer Rejects-COB 2 | Enter the other payer reject codes (maximum of 3). |
69 | Dosage Form Description Code-Compound | Enter the dosage form description code. |
70 | Dispensing Unit Form Indicator-Compound | Enter the dispensing unit form indicator. |
71 | Route of Administration | Enter the SNOMED route of administration code. |
72 | Ingredient Component Count-Compound | Enter the ingredient component count code. |
73 | Product Name-Compound | Enter the product name (maximum of 25). |
74 | Product ID-Compound | Enter the product ID (maximum of 25). |
75 | Qual-Compound | Enter the product ID number qualifier (maximum of 25). |
76 | Ingredient QTY-Compound | Enter the ingredient quantity. |
77 | Ingredient Drug Cost-Compound | Enter the ingredient drug cost associated with the product ID. |
78 | Basis of Cost-Compound | Enter the basis of cost code. |
79 | Usual & Customary Charge-Pricing | Enter the usual and customary charge. |
80 | Basis of Cost Det.-Pricing | Enter the basis of cost determination. |
81 | Ingredient Cost Submitted Enter | Enter the submitted ingredient cost. |
82 | Dispensing Fee Submitted-Pricing | Enter the submitted dispensing fee. |
83 | Prof Service Fee Submitted-Pricing | Enter the submitted professional service fee. |
84 | Incentive Amount Submitted-Pricing | Enter the submitted incentive amount. |
85 | Other Amount Submitted-Pricing | Enter the submitted other amount. |
86 | Sales tax Submitted-Pricing | Enter the submitted sales tax. |
87 | Gross Amount Due (submitted)-Pricing | Enter the submitted gross amount due. |
88 | Member Paid Amount | Enter the amount paid by the member. |
89 | Other Payer Amount Paid #1-Pricing | Enter the other payer amount paid by the first other payer (if present). |
90 | Other Payer Amount Paid #2 | Enter the other payer amount paid by the second other payer (if present). |
91 | Other Payer Member Resp. Amount #1-Pricing | Enter the other payer member responsibility amount from the first other Payer (if present). |
92 | Payer Member Resp. Amount #2-Pricing | Enter the other payer member responsibility amount from the second other Payer (if present). |
93 | Net Amount Due-Pricing | Enter the net amount due. |
The forms below and others are available on the Forms page of the Provider Information website:
This edition has three search options.
This publication supersedes all previous Prescription Drug Program Manuals. Published by the Montana Department of Public Health & Human Services, July 2001.
Updated October 2001, December 2001, May 2002, June 2002, September 2002, January 2003, August 2003, July 2004, November 2004, May 2011, August 2011, October 2011, December 2011, January 2013, March 2013, July 2013, September 2013, March 2015, June 2015, January 2016, July 2016, October 2016, December 2016, August 2017, February 2018, July 2018, November 2018, July 2019, January 2020, July 2020, April 2021, October 2021, and July 2022.
CPT codes, descriptions and other data only are copyright 2014 American Medical Association (or such other date of publication of CPT). All Rights reserved. Applicable FARS/DFARS Apply.
07/21/2022
10/26/2021
Updated Montana Healthcare Programs Covered Products and Reimbursement chapters.
04/13/2021
Added the COVID-19 vaccine administration rates to the Reimbursement chapter.
07/01/2020
Updated dispensing fees and the vaccine administration fee.
01/01/2020
07/08/2019
References to the MA-5 were replaced with references to the Universal Claim Form Version 1.2-02/2013 throughout the manual. Instructions for the Universal Claim Form replaced instructions for the MA-5 form. Seasonale® removed from the 34-day supply exception list. Vasopressors-midodrine removed from the drug classes considered for maintenance medications list.
11/27/2018
Reimbursement Chapter was updated with current rates.
07/31/2018
How to Bill Pharmacy Claims was added to the Billing Procedures chapter and obsolete language was removed from the Drug Program chapter.
07/10/2018
Dispensing Limitations was updated.
02/9/2018
Reimbursement rates were updated in the Reimbursement chapter.
09/26/2017
A portion of the Federal Maximum Allowable Cost section in the Reimbursement chapter was eliminated.
08/08/2017
Mental Health Services - Adult Manual converted to an HTML format and adapted to 508 Accessibility Standards.
06/15/2016
Prescription Drug Program, July 2016: Cost Share Updates
12/31/2015
Prescription Drug Program, January 2016: HELP Plan-Related Updates and Others
07/21/2015
Prescription Drug Program, Prior Authorization, Reimbursement, and Billing Procedures
03/25/2015
Prescription Drug Program, Entire Manual
09/27/2013
Prescription Drug Program, Reimbursement
09/05/2013
Prescription Drug Program, Entire Manual Including the New Passport Chapter. This set of replacement pages contains a terminology change ("client" to "member"); however, only content changes are marked with a change bar (black line).
04/17/2013
Prescription Drug Program, Key Contacts and Reimbursement
02/04/2013
Prescription Drug Program, Medicaid Covered Products
02/01/2012
Prescription Drug Program, Multiple Chapters
09/01/2011
Prescription Drug Program, Medicaid Covered Services and Reimbursement (Dispensing Fee) and MHSP Covered Products (Formulary Drugs)
06/17/2011
Prescription Drug Program; Entire manual has changed from last posted version.
11/16/2004
Prescription Drug Program, Updated Prescription Drug Prior Authorization Criteria
06/16/2004
Prescription Drug Program, Prior Authorization and HIPAA Updates
06/10/2004
Prior Authorization Additions
For all questions regarding drug prior authorization:
(800) 395-7961
(406) 443-6002 (Helena)
8 a.m. to 5 p.m., Monday–Friday
Mountain Time
Mail or fax backup documentation to:
Mountain-Pacific Quality Health
P.O. Box 5119
Helena, MT 59604
(800) 294-1350 Fax
(406) 513-1928 Fax Helena
For assistance with online POS claims adjudication:
Conduent, Atlanta
Technical POS Help Desk
(800) 365-4944
6 a.m. to midnight, Monday–Saturday;
10 a.m. to 9 p.m., Sunday
Eastern Time
For program policy questions:
(406) 444-2738 Phone
(406) 444-1861 Fax
Allied Health Services Bureau
1400 Broadway
P.O. Box 202951
Helena, MT 59620
Thank you for your willingness to serve members of the Montana Healthcare Programs administered by the Department of Public Health and Human Services.
This manual provides information specifically for Prescription Drug Program providers. Other essential information for providers is contained in the separate General Information for Providers Manual. Providers are responsible for reviewing both manuals.
Notification of manual updates are provided through the weekly web postings under “Recent Website Posts” on the Home page of the Provider website. Older versions of the manual may be found through the Archive page on the Provider Information website. 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 make sure that the policy they are researching or applying has the correct effective date for their circumstances.
Providers must be familiar with all current rules and regulations governing the Montana Healthcare Programs. Provider manuals are to assist providers in billing Montana Healthcare Programs; they do not contain all Montana Healthcare Programs rules and regulations. Rule citations in the text are a reference tool; they are not a summary of the entire rule. If a manual conflicts with a rule, the rule prevails. Links to rules are available on the Provider Information website. Paper copies of rules are available through the Secretary of State’s office. In addition to the general Montana Healthcare Programs rules outlined in the General Information for Providers Manual, the following rules and regulations are also applicable to the Prescription Drug Program:
The Department is committed to paying Montana Healthcare Programs providers’ claims as quickly as possible. Montana Healthcare Programs claims are electronically processed and usually are not reviewed by medical experts prior to payment to determine if the services provided were appropriately billed. Although the computerized system can detect and deny some erroneous claims, there are many erroneous claims which it cannot detect. For this reason, payment of a claim does not mean that the service was correctly billed, or the payment made to the provider was correct. Periodic retrospective reviews are performed which may lead to the discovery of incorrect billing or incorrect payment. If a claim is paid and the Department later discovers that the service was incorrectly billed or paid or the claim was erroneous in some other way, the Department is required by federal regulation to recover any overpayment, regardless of whether the incorrect payment was the result of Department or provider error or other cause.
The provider manuals are designed to answer most questions; however, questions may arise that require a call to a specific group (such as a program officer, Provider Relations, or a prior authorization unit). The Key Contacts chapter and the Contact Us link on the Provider Information website have important phone numbers and addresses. Montana Healthcare Programs manuals, provider notices, fee schedules, forms, and more are available on the Provider Information website.
The Prescription Drug Program covers pharmaceuticals and pharmacist services to members served by the Department in the Montana Healthcare Programs and the Mental Health Services Plan (MHSP).
Primary authority for the prescribing of legend drugs and controlled substances comes from individual professional practice acts, usually in the section of the act which defines the scope of practice for the profession. The definition of scope of practice is the responsibility of the board that licenses the professional. Only those providers not excluded by federal programs are eligible.
The Drug Use Review (DUR) Board performs drug utilization review and educational interventions. Five pharmacists and four physicians comprise the DUR Board which is coordinated by a full-time registered Montana pharmacist. The DUR Board meets monthly to review utilization and advise the Department.
Drug Use Review (DUR) Board meetings are posted on the Provider website. On the Pharmacy page, click on the Drug Use Review (DUR) Board pane.
The DUR Board and The University of Montana Skaggs School of Pharmacy also advise the Department on its outpatient drug formulary. Drugs are evaluated for safety, effectiveness, and clinical outcome. Drugs recommended for formulary exclusion have no significant, clinically meaningful therapeutic advantage over drugs recommended for inclusion.
Drug coverage is limited to those products where the pharmaceutical manufacturer has signed a rebate agreement with the federal government. Federal regulations further allow states to impose restrictions on payment of prescription drugs through prior authorization and preferred drug lists (PDL).
The Montana Healthcare Programs Prescription Drug Program covers the following:
The Montana Healthcare Programs Prescription Drug Program does not reimburse for the following items or services:
To address the rising costs of prescription drugs, Montana Healthcare Programs implemented a preferred drug list (PDL) in 2005. The Department of Public Health and Human Services uses this program to provide clinically effective and safe drugs to its members at the best available price.
The PDL addresses certain classes of medications and provides a selection of therapeutically effective products for which the Montana Healthcare Programs will allow payment without restriction in those targeted classes. The Department, through its Formulary Committee, designates this listing of preferred drugs as “preferred” based primarily on clinical efficacy. In the designated classes, drug products that are non-preferred on the PDL will require prior authorization.
The Department updates the PDL annually and periodically as new drugs and information become available.
The current Montana PDL can be found on the Preferred Drug Information tab on the Pharmacy Page of the Provider Information website. Providers may address questions regarding the PDL and requests for prior authorization to the Drug Prior Authorization Unit. (See the Key Contacts chapter) The PDL/Prior Authorization Help Line is for providers only. Montana Healthcare Programs members with questions can ask their providers or call the Member Help Line, (800) 362-8312.
Part D
Medicare added prescription drug coverage for its beneficiaries under the Medicare Modernization Act, 42 USC 1302 Sec. 1395. Members enrolled in Medicare Part A and/or Part B are eligible for Medicare Part D and are required to receive their drug benefits through a Medicare Prescription Drug Plan (PDP). Members enrolled in both Montana Healthcare Programs and Medicare are considered “dual eligible” and are auto-enrolled in a Medicare PDP if they do not choose a plan. The Montana Healthcare Programs reimbursement for outpatient drugs provided to a full-benefit dual eligible member will be limited to the excluded drugs identified in this chapter and the Part B drugs described in the following paragraph.
Part B
Claims cross over automatically if the provider’s NPI/API is on file with Montana Healthcare Programs. The taxonomy code for the pharmacy is required on the claim.
To bill paper claims:
Montana Healthcare Programs allowed for the pharmacy supplying and dispensing fee is $4.94.
For an updated list of covered Part B drugs, visit the CMS website, https://www.cms.gov.
The MHSP formulary includes the following types of drugs:
Refer to the MHSP formulary on the Pharmacy page of the Provider Information website.
Medications may not be dispensed in quantities greater than a 34-day supply except where manufacturer packing cannot be reduced to a smaller quantity.
1. The following drug classes are considered maintenance medications and may be dispensed up to a 90-day supply.
Cardiovascular (Heart Health)
Diabetes
Central Nervous System
Gastrointestinal
Renal System
Respiratory
Men and Women’s Health
Other Body Systems
2. No more than two prescriptions of the same drug may be dispensed in a calendar month except for the following:
The DUR Board has set monthly limits on certain drugs. Use over these amounts requires prior authorization.
Prescriptions for non-controlled substances may be refilled after 75% of the estimated therapy days have elapsed. Prescriptions for controlled substances (CII-CV), Ultram (tramadol), Ultracet (tramadol/acetaminophen), carisoprodol, and gabapentin may be refilled after 90% of the estimated therapy days have elapsed. The POS system will deny a claim for “refill to soon” based on prescriptions dispensed on month-to-month usage.
A prescription may be refilled early only if the prescriber changes the dosage, or if the member was admitted to a nursing facility. The pharmacist must document any dosage change. In any circumstance, the provider must contact the Drug Prior Authorization Unit to receive approval. (See Key Contacts.)
Pharmacists who identify members who experience difficulties in managing their drug therapy may consider unit dose prescriptions (see below).
The Department has a mandatory generic edit in the claims processing system. The edit is enabled once there are two rebateable AB-rated generic drugs available in the marketplace. Typically, the first generic labeler will have a six-month period of market exclusivity. To maximize value to the State, the Department recommends dispensing the brand name drug over the generic during this period of market exclusivity. Brands may be preferred over generics in other instances where there is a net cost benefit to the Department. Brand over generic preferences are listed on the PDL. When there are “preferred brands” on the Department’s PDL, generic equivalent drugs will require a prior authorization.
For drugs not subject to PDL restrictions and for those drugs listed in the Dispense As Written (DAW) section of the Billing Procedures chapter, if the brand name drug is prescribed instead of a generic equivalent, the prescriber must get prior authorization.
Authorization is based on medical need such as adverse reactions or therapeutic failures (clinically demonstrated, observed and documented) which have occurred when the generic drug has been used.
Pharmacy-packaged unit dose medications may be used to supply drugs to members in nursing facilities, group homes, and other institutional settings.
Members who are not in one of the above facilities may also be considered high-risk and eligible for unit dose packaging if they:
Unit dose prescriptions may not exceed the 34-day supply limit.
The Department shall reimburse pharmacies for compounding drugs only if the member’s drug therapy needs cannot be met by commercially available dosage strengths and/or forms of the therapy.
Prescription claims for compound drugs shall be billed and reimbursed using the National Drug Code (NDC) number and quantity for each compensable ingredient in the compound. No more than 25 ingredients may be reimbursed in any compound. Reimbursement for each drug component shall be determined in accordance with ARM 37.86.1101. Prior authorization requirements for individual components of a compound must be met for reimbursement purposes. The Department does not consider reconstitution to be compounding.
The Department may reimburse for compounded non-rebateable API bulk powders and excipients on the Department’s drug formulary maintained in accordance with ARM 37.86.1102.
Many drug products require prior authorization before the pharmacist provides them to the member. Requests are reviewed for medical necessity.
Drug Prior Authorization Unit
Mountain-Pacific Quality Health
P.O. Box 5119
Helena, MT 59604
(406) 443-6002 or 800-395-7961 (Phone)
(406) 513-1928 or 800-294-1350 (Fax)
All prior authorization requirements must be met for retroactively eligible members.
When a member is determined retroactively eligible for Montana Healthcare Programs, the member should give the provider a Notice of Retroactive Eligibility (160-M).
The provider has 12 months from the date retroactive eligibility was determined to bill for those services.
Retroactive Montana Healthcare Programs eligibility does not allow a provider to bypass prior authorization requirements.
When a member becomes retroactively eligible for Montana Healthcare Programs, the provider may:
Providers may choose whether to accept retroactive eligibility. (See the General Information for Providers Manual, Member Eligibility and Responsibilities chapter.) All prior authorization requirements must be met to receive Montana Healthcare Programs payment.
When submitting claims for retroactively eligible members, attach a copy of the Notice of Retroactive Eligibility (Form 160-M) to the claim if the date of service is more than 12 months earlier than the date the claim is submitted.
For a list of drugs requiring prior authorization, contact the Drug Prior Authorization Unit. (See Key Contacts.)
Reimbursement for covered brand and generic preferred drugs shall not exceed the lowest of:
Average Acquisition Cost
Average acquisition cost (AAC) is the calculated average drug ingredient cost per drug determined by direct pharmacy survey, wholesale survey, and other relevant cost information. The AAC rates are published online under the Pharmacy Provider webpage.
Submitted Ingredient Cost
Submitted Ingredient is a pharmacy’s actual ingredient cost. For drugs purchased under the 340B Drug Pricing Program, submitted ingredient cost means the actual 340B purchase price. For drugs purchased under the Federal Supply Schedule (FSS), submitted ingredient cost means the actual FSS purchase price.
The usual and customary charge is the price the provider most frequently charges the general public for the same drug. In determining “usual and customary” prices, the Department:
Federal Maximum Allowable Cost (MAC)
Dispensing Fee
Pharmacies can receive a vaccine administration fee. This fee is in lieu of the standard dispensing fee. The fee for the first vaccine administered will be $21.32; the fee for each additional vaccine administered will be $15.65.
For the COVID-19 vaccine, Montana Healthcare Programs will follow the Medicare established rates for the administration fee, which are different from the above rates.
The remittance advice is the best tool providers have to determine the status of a claim. Remittance advices accompany payment for services rendered. The remittance advice provides details of all transactions that have occurred during the previous remittance advice cycle. Each line of the remittance advice represents all or part of a claim and explains whether the claim or service has been paid, denied, or suspended (also referred to as pending). If the claim was suspended or denied, the remittance advice also shows the reason. See the General Information for Providers manual for more information on the remittance advice.
As of July 2013, all new providers were required to enroll in electronic funds transfer (EFT) and receive electronic remittance advices. Providers who enrolled prior to July 2013 who received paper checks or paper remittance advices were transitioned to the electronic-only system over time.
Credit balances occur when claim adjustments reduce original payments causing the provider to owe money to the Department. These claims are considered in process and continue to appear on the remittance advice until the credit has been satisfied. Credit balances can be resolved in two ways:
Rebillings and adjustments are important steps in correcting any billing problems you may experience. Knowing when to use the rebilling process versus the adjustment process is important. When submitting a reversal (void) use a B2 NCPDP transaction and when submitting a rebilled claim or an adjustment use a B3 NCPDP transaction (void & rebill).
Timeframe for Rebilling or Adjusting a Claim
Rebilling Montana Healthcare Programs
Rebilling is when a provider submits a claim or claim line to Montana Healthcare Programs that was previously submitted for payment but was either returned or denied. Pharmacy providers can rebill Montana Healthcare Programs via point-of-sale or on paper. Paper claims are often returned to providers before processing because information such as the NPI or authorized signature/date are missing or unreadable. See the Billing Procedures chapter for tips on preventing returned or denied claims.
When to Rebill Montana Healthcare Programs
How to Rebill
Adjustments
If a provider believes that a claim has been paid incorrectly, the provider may call Provider Relations. Once an incorrect payment has been verified, the provider may submit an Individual Adjustment Request form to Provider Relations or submit an adjustment through point-of-sale. If incorrect payment was the result of a Conduent keying error, the provider should contact Provider Relations.
When adjustments are made to previously paid claims, the Department recovers the original payment and issues appropriate repayment. The result of the adjustment appears on the provider’s RA as two transactions. The original payment will appear as a credit transaction. The replacement claim reflecting the corrections will be listed as a separate transaction and may or may not appear on the same remittance advice as the credit transaction. The replacement transaction will have nearly the same ICN number as the credit transaction, except the 12th digit will be a 2, indicating an adjustment. Adjustments are processed in the same time frame as claims.
When to Request an Adjustment
How to Request an Adjustment
To request an adjustment, use the Individual Adjustment Request form. Adjustments may also be made using point-of-sale. The requirements for adjusting a claim are as follows:
Completing an Adjustment Request Form
Section A
Field: 1. Provider Name and Address
Description: Provider’s name and address (and mailing address if different).
Field: 2. Member Name
Description: The member’s name.
Field: 3.* Internal Control Number (ICN)
Description: There can be only one TCN per Adjustment Request form. When adjusting a claim that has been previously adjusted, use the TCN of the most recent claim.
Field: 4*. Provider NPI/API
Description: The provider’s NPI/API
Field: 5*. Member's Montana Healthcare Programs Number
Description: Member's Montana Healthcare Programs ID number.
Field: 6. Date of Payment
Description: Date claim was paid found on Remittance Advice Field 5 (see the sample RA earlier in this chapter).
Field: 7. Amount of Payment
Description: The amount of payment from the Remittance Advice Field 19 (see the sample RA earlier in this chapter.).
Section B
Field: 1. Units of Service
Description: If a payment error was caused by an incorrect number of units, complete this line.
Field: 2. Procedure Code/NDC/Revenue Code
Description: If the procedure code, NDC, or revenue code are incorrect, complete this line.
Field: 3. Dates of Service (DOS)
Description: If the date of service is incorrect, complete this line.
Field: 4. Billed Amount
Description: If the billed amount is incorrect, complete this line.
Field: 5. Personal Resource (Nursing Facility)
Description: If the member's personal resource amount is incorrect, complete this line.
Field: 6. Insurance Credit Amount
Description: If the member’s insurance credit amount is incorrect, complete this line.
Field: 7. Net (Billed - TPL or Medicare Paid)
Description: If the payment error was caused by a missing or incorrect insurance credit, complete this line. Net is billed amount minus the amount TPL or Medicare paid.
Field: 8. Other/Remarks
Description: If none of the above items apply, or if you are unsure what caused the payment error, complete this line.
*Indicates a required field
Mass Adjustments
Mass adjustments are done when it is necessary to reprocess multiple claims. They generally occur when:
Providers receive their Montana Healthcare Programs payment and remittance advices weekly. To sign up for EFT (direct deposit) and register for the web portal to view or download remittance advices, providers need to complete the EFT and ERA Authorization Agreement and the EDI Trading Partner Agreement and mail or fax them to Provider Relations. See the Provider Enrollment page for those documents.
A letter from your financial institution verifying legitimacy of the account is also required. The letter must include the name and contact information of the bank representative and be signed by the bank representative. Do not send voided checks or deposit slips.
Once enrolled in EFT and registered for the MATH web portal, providers are able to receive their electronic remittance advices. Due to space limitations, each remittance advice is available on the web portal for 90 days.
For assistance on enrolling in EFT, completing the EDI Trading Partner Agreement, and registering for the MATH web portal, contact Provider Relations.
Provider Enrollment
P.O. Box 4936
Helena, MT 59604
(800) 624-3958
(406) 442-1837
Written prescriptions must contain all of the following.
Outpatient pharmacy claims for Montana Healthcare Programs and MHSP require the prescription origin code to indicate the source of the prescription. Valid values for prescription origin code are:
Providers are required to submit a clean claim no later than 365 days from:
A clean claim is one that can be adjudicated without correction or additional information or documentation from the provider.
Prescription Tracking and Claim Reversals
For purposes of billing for prescribed drugs, the date of service means the date a prescription is filled. If the drug has not been received by the member or the member’s representative within 15 days after the prescription is filled, the pharmacy must reverse the claim and refund the payment to the Department.
Tips to Avoid Timely Billing Denials
In most circumstances, providers may not bill Montana Healthcare Programs members for services covered under Montana Healthcare Programs. More specifically, providers cannot bill members directly:
Under certain circumstances, providers may need a signed agreement in order to bill a Montana Healthcare Programs member (see the following table).
Routine Agreement: This may be a routine agreement between the provider and member which states that the member is not accepted as a Montana Healthcare Programs member, and that he/she must pay for the services received.
Custom Agreement: This agreement lists the service the member will receive and states that the service is not covered by Montana Healthcare Programs and that the member will pay for the services received.
When the provider accepts the member’s retroactive eligibility, the provider has 12-months from the date retroactive eligibility was determined to bill for those services.
When submitting claims for retroactively eligible members in which the date of service is more than 12 months earlier than the date the claim is submitted, attach a copy of the Provider Notice of Eligibility (Form 160-M). The provider must request the form from the member’s local Office of Public Assistance.
See https://dphhs.mt.gov/hcsd/OfficeofPublicAssistance. For more information on retroactive eligibility, see the Member Eligibility and Responsibilities chapter in the General Information for Providers Manual.
Providers should bill Montana Healthcare Programs their usual and customary charge for each service; that is, the same charge that is made to other payers for that service.
Effective for all claims paid on or after January 1, 2020 co-payment will not be assessed. For members with Mental Health Services Plan (MHSP) coverage, there is a $425 pharmacy cap. The MHSP program pays for the first $425 in prescriptions for the member each month, and the member must pay privately for any amounts over that cap.
The provider must always use the complete 11-digit NDC from the dispensing container.
All outpatient prescription drugs are billed using the drug’s NDC, the 11-digit code assigned to all prescription drug products by the labeler or distributor of the product under FDA regulations.
The Department accepts only the 5-4-2 NDC format. All 11 digits, including zeros, must be entered. The three segments of the NDC are:
SAMPLE NDC: 12345-6789-10
12345 = labeler code
6789 = product code
10 = package size
Claims must accurately report the NDC dispensed, the number of units dispensed, days supply, and the date of dispensing. Use of an incorrect NDC or inaccurate reporting of a drug quantity will cause the Department to report false data to drug manufacturers billed for drug rebates.
The Department will recover payments made on erroneous claims discovered during dispute resolution with drug manufacturers. Pharmacies are required to document purchase for quantities of brands of drugs reimbursed by the Department if disputes occur.
Prescribers and pharmacies must prescribe and dispense the generic form of a drug whenever possible. Except for those drugs listed below, prior authorization is required when a brand name drug is prescribed instead of a generic equivalent. Please use the following DAW codes for these situations:
The following practices constitute abuse and misutilization:
Montana Healthcare Programs will not approve a claim with a negative payment amount (from click fees or PBM clawbacks) or allow pharmacies to bypass the primary insurance to eliminate the negative payment amount. If a pharmacy receives a negative amount from the primary insurance and a member has Montana Healthcare Programs as secondary, the pharmacy must bill with the following to receive payment from the Department:
In addition, providers are reminded that aside from a member copayment, if there is one, payment from Montana Healthcare Programs is payment in full. Negative payment amounts may not be passed on to members.
Pharmacies who fill medications for PRTFs are able to bill for non-psychotropic medications for members currently in an all-inclusive PRTF by submitting the claim with a submission clarification code (SCC) of 10 in NCPDP field (420-DK). If these pharmacies receive a claim rejection of “member enrolled in all-inclusive program, contact facility for payment” despite submitting with a SCC code of 10, this indicates the medication being billed is classified as a psychotropic medication and can’t be reimburse through the pharmacy benefit. Psychotropic medications are included in the all-inclusive payment and must be billed to the facility. However, if the medication is on the psychotropic list but is being used for a non-psychiatric diagnosis, a prior authorization may be obtained by calling the Drug Prior Authorization Unit at (406) 443-6002 or (800) 395-7961.
If pharmacies are trying to bill prescriptions for a member that has been released from an all-inclusive facility but are still getting denied claims with the same rejection referenced above, please contact the Pharmacy Program Officer or the Montana Healthcare Programs Pharmacist.
The point-of-sale (POS) system finalizes claims at the point of entry as either paid or denied. Pharmacies arrange their own telecommunications switch services to accept Montana Healthcare Programs point of sale and are responsible for any charges imposed by these vendors. Hard copy (paper) billing is still accepted when billed on a Universal Claim Form Version 1.2-02/2013. All claims are processed and edited through the POS system regardless of how the claim was originally submitted.
If the claim continues to deny for eligibility past 3 working days, call Provider Relations at (800) 624-3958.
Possession of a Montana Access to Health (MATH) Montana Healthcare Programs ID card is not proof of eligibility.
Member eligibility may change monthly, so providers should verify eligibility each month. Both the 7-digit member number and the member’s Social Security number are billable numbers. If a claim is rejected online, a provider should verify eligibility by one of the methods (MATH web portal, IVR, FaxBack, calling Provider Relations) described in the General Information for Providers Manual.
The POS system performs all major prospective drug utilization review (Pro-DUR) edits. In some circumstances, the Pro-DUR edits result in denied claims. When a Pro-DUR denied claim needs to be overridden, pharmacy providers may enter one Reason for Service Code (formerly DUR Conflict Code) from each category in the following order, as long as the indicated situations exist and the pharmacy retains documentation in its files:
By placing codes into the claim, the provider is certifying that the indicated DUR code is true and documentation is on file. For questions regarding DUR codes, contact the Drug Prior Authorization Unit.
Providers may also request online login access from CommuniForm LLC by calling (877) 817-3676. Forms can be ordered online by logging in at https://www.asbaces.com/NEWACES/(S(exhfqdwrar3yfin0ozystqw0))/storefront.aspx.
For MHSP claims, clearly write MHSP ONLY on the face of each paper claim.
Paper claims must be mailed to the following address:
Claims Processing Unit
P.O. Box 8000
Helena, MT 59604
Field Number | Field Title | Instructions |
---|---|---|
1 | ID-Insurance | Enter the Member ID. |
2 | Group ID-Insurance | Enter the insurance Group ID. |
3 | Last-Insurance | Enter the last name of the member |
4 | First-Insurance | Enter the first name of the member. |
5 | Plan Name-Insurance | Enter the plan name for the member. |
6 | BIN #-Insurance | Enter the BIN number from the member ID Card. |
7 | Processor Control #-Insurance | Enter the PCN number from the member ID card. |
8 | CMS Part D Defined Qualified Facility | Enter a "Y" or "N" if the pharmacy is a CMS Part D Defined Qualified Facility. |
9 | Last-Member | Enter the member last name. |
10 | First-Member | Enter the member first name. |
11 | Person Code-Member | Enter the three digit person code. |
12 | D.O.B.-Member | Enter the member date of birth in MM-DD-CCYY format. |
13 | Gender-Member | Enter the member gender code. |
14 | Relationship-Member | Enter the relationship code between the member and cardholder. |
15 | Member Residence-member | Enter the member residence code. |
16 | DO NOT USE | Leave this field blank. |
17 | Service Provider ID-Pharmacy | Enter the pharmacy ID. |
18 | Qualifier-Pharmacy | Enter the service provider ID qualifier code. |
19 | Name-Pharmacy | Enter the name of the pharmacy. |
20 | Telephone #-Pharmacy | Enter the telephone number for the pharmacy. |
21 | Address-Pharmacy | Enter the address of the pharmacy. |
22 | City-Pharmacy | Enter the city of the pharmacy. |
23 | State-Pharmacy | Enter the State of the Pharmacy. |
24 | Zip-Pharmacy | Enter the zip code for the pharmacy. |
25 | Signature of Provider | The provider must sign this field. |
26 | Date | Enter the date in which the provider signed the paper claim. |
27 | ID-Prescriber | Enter the ID for the prescribing provider. |
28 | Qualifier-Prescriber | Enter the the prescriber ID qualifier. |
29 | Last Name-Prescriber | Enter the prescriber's last name. |
30 | ID-Pharmacist | Enter the pharmacist's ID number. |
31 | Qualifier-Pharmacist | Enter the pharmacist's ID qualifier. |
32 | Prescription/Service Ref. #-Claim | Enter the Prescription or reference number. |
33 | Qual-Claim | Enter the prescription or service ID qualifier. |
34 | Fill #- Claim | Enter the fill number. |
35 | Date Written-Claim | Enter the date the prescription was written. |
36 | Date of Service-Claim | Enter the date of service. |
37 | Submission Clarification-Claim | Enter the submission clarification code. |
38 | Prescription Origin-Claim | Enter the prescription origin code. |
39 | Pharmacy Service Type-Claim | Enter the pharmacy service type code. |
40 | Special Packaging Indicator-Claim | Enter the special packaging indicator code. |
41 | Product/Service ID-Claim | Enter the product/service ID. |
42 | Qual-Claim | Enter the product/service ID qualifier. |
43 | Product Description-Claim | Enter the product description. |
44 | Quantity Dispensed-Claim | Enter the quantity dispensed. |
45 | Days Supply-Claim | Enter the days supply dispensed. |
46 | DAW Code- Claim | Enter the appropriate DAW code. |
47 | Prior Auth # Submitted-Claim | Enter the prior authorization number submitted. |
48 | PA Type-Claim | Enter the prior authorization type code. |
49 | Other Coverage-Claim | Enter the appropriate other coverage code, if applicable. |
50 | Delay Reason-Claim | Enter the appropriate delay reason code. |
51 | Level of Service-Claim | Enter the level of service. |
52 | Place of Service-Claim | Enter the place of service. |
53 | Quantity Prescribed-Claim | Enter the total quantity prescribed. |
54 | Diagnosis Code-Clinical | Enter the appropriate diagnosis code. |
55 | Qual-Clinical | Enter the diagnosis code qualifier. |
56 | DUR/PPS Codes- Reason-DUR | Enter the DUR/PPS reason for service code. |
57 | DUR/PPS Codes-Service-DUR | Enter the DUR/PPS service code. |
58 | DUR/PPS Codes-Result-DUR | Enter the DUR/PPS result of service code. |
59 | Level of Effort-DUR | Enter the level of effort-required when billing a compound. |
60 | Procedure Modifier-DUR | Enter the procedure modifier. |
61 | Other Payer ID-COB 1 | Enter the other payer ID when COB is present. |
62 | Qual-COB 1 | Enter the other payer ID qualifier. |
63 | Other Payer Date-COB 1 | Enter the date in which the other payer paid the claim. |
64 | Other Payer Rejects-COB 1 | Enter the other payer reject codes (maximum of 3). |
65 | Other Payer ID-COB 2 | Enter the other payer ID when COB is present. |
66 | Qual-COB 2 | Enter the other payer ID qualifier. |
67 | Other Payer Date-COB 2 | Enter the date in which the other payer paid the claim. |
68 | Other Payer Rejects-COB 2 | Enter the other payer reject codes (maximum of 3). |
69 | Dosage Form Description Code-Compound | Enter the dosage form description code. |
70 | Dispensing Unit Form Indicator-Compound | Enter the dispensing unit form indicator. |
71 | Route of Administration | Enter the SNOMED route of administration code. |
72 | Ingredient Component Count-Compound | Enter the ingredient component count code. |
73 | Product Name-Compound | Enter the product name (maximum of 25). |
74 | Product ID-Compound | Enter the product ID (maximum of 25). |
75 | Qual-Compound | Enter the product ID number qualifier (maximum of 25). |
76 | Ingredient QTY-Compound | Enter the ingredient quantity. |
77 | Ingredient Drug Cost-Compound | Enter the ingredient drug cost associated with the product ID. |
78 | Basis of Cost-Compound | Enter the basis of cost code. |
79 | Usual & Customary Charge-Pricing | Enter the usual and customary charge. |
80 | Basis of Cost Det.-Pricing | Enter the basis of cost determination. |
81 | Ingredient Cost Submitted Enter | Enter the submitted ingredient cost. |
82 | Dispensing Fee Submitted-Pricing | Enter the submitted dispensing fee. |
83 | Prof Service Fee Submitted-Pricing | Enter the submitted professional service fee. |
84 | Incentive Amount Submitted-Pricing | Enter the submitted incentive amount. |
85 | Other Amount Submitted-Pricing | Enter the submitted other amount. |
86 | Sales tax Submitted-Pricing | Enter the submitted sales tax. |
87 | Gross Amount Due (submitted)-Pricing | Enter the submitted gross amount due. |
88 | Member Paid Amount | Enter the amount paid by the member. |
89 | Other Payer Amount Paid #1-Pricing | Enter the other payer amount paid by the first other payer (if present). |
90 | Other Payer Amount Paid #2 | Enter the other payer amount paid by the second other payer (if present). |
91 | Other Payer Member Resp. Amount #1-Pricing | Enter the other payer member responsibility amount from the first other Payer (if present). |
92 | Payer Member Resp. Amount #2-Pricing | Enter the other payer member responsibility amount from the second other Payer (if present). |
93 | Net Amount Due-Pricing | Enter the net amount due. |
The forms below and others are available on the Forms page of the Provider Information website:
This edition has three search options.