The Montana Department of Public Health and Human Services contracts with Mountain-Pacific to review requests to determine medical necessity for admission to Home and Community Based Waiver Services (HCBS), Serious and Disabling Mental Illness Waiver Services (SDMI) and nursing facility services. Review requests must be submitted to Mountain-Pacific prior to the admission.
This review consists of two functions:
• Level-of-care review – Review for Medicaid eligible and those pending Medicaid eligibility to determine
medical necessity using Department-developed criteria.
• PASRR (level 1) review – Review to determine indicators of mental illness or mental retardation/related conditions. If indicators are identified, the case is referred to a specialist who makes a diagnosis and provides direction for access to long term care services.
Procedures – Requests for services are received by fax or phone from any entity knowledgeable of the client’s need for long-term care services. When Level 1 reviews are received by 3:00 PM, they are reviewed the same day. If after 3:00 PM, they are reviewed the morning of the following business day. Level-of-care reviews are initiated within three business days of receipt at Mountain-Pacific.
Mountain-Pacific staff can be reached at 800-219-7035 or by fax at 800-413-3890.
Process – Mountain-Pacific nurses and social workers work as a team to assure adherence to the Administrative Rules of Montana and determine medical necessity. This review consists of phone interviews with the appropriate parties to determine the clients overall medical/psychological status and the ADL/IADL needs.
Determination– Notification of authorization is faxed or mailed to all appropriate parties. Denial of services is mailed to the client and/or their representative.