The Montana Department of Public Health and Human Services contracts with Mountain-Pacific to review requests for specific medical/surgical procedures that have been identified by the department. Mountain-Pacific began providing this review service January 1, 2007.
Procedures – Registered nurses and physicians at Mountain-Pacific work with providers to determine appropriateness for selected medical/surgical procedures. Some examples of procedures requiring prior authorization are circumcisions, breast reductions and Botox injections.
To determine what services require prior authorization, go to mtmedicaid.org. The fee schedule on this website provides updated and current prior authorization information.
Providers submit a fax for the service being requested. Documentation needed includes a physician order, physician notes, Medicaid DME form or other clinical information. Medical-surgical procedures can be authorized on a retrospective basis.
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. Medical/surgical procedures must be
• a covered Medicaid service,
• a service determined by the department to require prior authorization,
• medically necessary and meets the Medicare or Department’s criteria,
• the least-costly option,
• provided to a Medicaid-eligible client, and
• ordered by a physician with the physician order included.
Determination – If a service is authorized, Mountain-Pacific will notify the provider by fax and generate a prior authorization number. When the service is denied, a denial letter with appeal rights will be mailed to the provider and the client to notify them of the reason for the denial.