The Montana Department of Public Health and Human Services contracts with Mountain-Pacific to review requests for inpatient out of state hospital and rehabilitation services. Review requests must be submitted to Mountain-Pacific prior to a planned admission or within 48 business hours of an emergent admission. If it is expected that Medicaid will reimburse on a claim with TPL as primary, review is required. If an individual is dually eligible for Medicare and Medicaid, review is required only if the procedure requested requires prior authorization, i.e. transplants, breast reduction, septorhinoplasty, etc.
Procedures – Mountain-Pacific’s nurse reviewers work with health care providers to determine medical necessity and whether the service is available in Montana. If the service is available in Montana, it may not be approved for out-of-state admission. Medical providers may phone or fax requests for services to Mountain-Pacific. Reviews will be initiated within two business days of receipt. Clinical documentation to support medical necessity for the service must accompany the request.
Mountain-Pacific staff can be reached at 800-262-1545 or by fax at 800-497-8235.
Process – Mountain-Pacific nurse reviewers assess the request to assure it meets the requirements of the Administrative Rules of Montana. In addition, the following requirements must be met:
• the service is a covered Medicaid service
• the service is medically necessary as defined by Interqual criteria
• the service is provided to a Medicaid-eligible client, and
• the provider is enrolled with MT Medicaid
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.