The Montana Department of Public Health and Human Services contracts with Mountain-Pacific to review requests for durable medical equipment, prosthetics, orthotics and supplies. Mountain-Pacific reviews all requests exceeding $1,000 or identified by the department as requiring prior authorization. Mountain-Pacific began this review service January 1, 2007.
Procedures – Mountain-Pacific’s nurses work with providers to determine appropriateness for selected durable medical equipment, prosthetics and orthotics. Providers submit a request by fax or mail for the item being requested. Information needed to process the request and determine medical necessity is dependent on the item requested. Documentation such as a physician notes, sleep study information, physical therapy evaluation, Medicaid DME form or other information may be needed. Requests for durable medical equipment (DME) must be received prior to the dispensing of the equipment. Retrospective authorization of this equipment is not allowed.
Mountain-Pacific staff can be reached at 877-443-4021, ext. 5887 or by fax at 877-443-2580.
Process – Mountain-Pacific nurse reviewers assess the request to assure it meets the requirements of the Administrative Rules of Montana. Durable medical equipment is reviewed to determine if it is:
• a covered-Medicaid service,
• the least-costly option,
• provided to a Medicaid-eligible client,
• medically necessary and meets the Medicare or Department’s criteria, and
• ordered by a physician with the physician order included.
To determine what services require prior authorization, go to mtmedicaid.org. The fee schedule on this website provides updated and current prior authorization information.
Determination – If an item/service is authorized, Mountain-Pacific will notify the provider by fax, and a prior authorization number will be generated. If an item/service is not approved, Mountain-Pacific will send denial letters with appeal rights to the client and the provider to notify them of the reason for the denial.